COVID Testing Consent Form
Concentric by Ginkgo, a service provided by Ginkgo Bioworks, Inc. (“Ginkgo”), is providing COVID-19 testing in the form of “pooled testing” to your school or organization (the “Program”). The Program will involve collecting nasal swabs from each participant on-site at your school or on the organization’s premises. Each swab will be placed in a common tube for that classroom or group and sent off and tested in a central laboratory. The test detects whether the virus that causes COVID-19 is present in that pooled sample. The purpose of this Program is to help school administrators make informed decisions about school/organization safety and operations. This test is intended to investigate the presence of COVID-19 within groups and should not be used for diagnostic purposes. Each participant must read and sign this form before taking part in the Program. If the participant is a student and/or a minor (under the age of 18), a parent or legal guardian must read and sign this form before the student or minor’s participation in the Program. If you are a parent or guardian, as used in this consent, “Minor” means the child or minor for which you are giving this consent.

Please carefully read and sign the following Consent:
a. I authorize the collection of my Minor’s swab sample for purposes of the Program.
b. I understand that the Program is testing students, staff, and/or employees as a collective group for COVID-19. Tests of this type are not required to be approved or authorized by the U.S. Food & Drug Administration (FDA), and I understand the test is not an FDA approved or authorized test nor a medical diagnostic test.
c. I understand that the purpose of the Program is to support school/organization administrators in their decision making about safety and operations at their school/facility and not for purposes of making individual clinical decisions.
d. I understand that a sample will be collected by inserting a nasal swab shallowly into each participant’s nose (including by self-collection) and that potential risks if performed as instructed include discomfort from the insertion of the swabs. Any irritation is expected to be brief. More information on the technique can be found at
https://www.concentricbyginkgo.com/instructions/.
e. I understand that the school will have access to test results from the Program.
f. I understand that, as with any COVID-19 test, there is the potential for a false positive or false negative test result and that the potential for a false negative COVID-19 test result may be higher with pooled testing than individual testing.
g. I understand that Ginkgo is researching aspects of the COVID-19 virus, such as tracking viral mutations; I authorize Ginkgo to sequence viruses and other microbes present in the samples for epidemiological and public health purposes.
I, the undersigned, have read the above information about the Program, the description of the test samples to be collected, and possible risks of the Program and I understand that this information may also be provided to me by Ginkgo upon written request to the school/organization. Additional information on Ginkgo testing can be found here: https://www.concentricbyginkgo.com/families. I voluntarily agree to participate (or allow Minor to participate) in the Program.

Sign in to Google to save your progress. Learn more
Email *
My role: *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Montgomery County Public Schools. Report Abuse