______________ PUBLIC SCHOOLS
_____________, Connecticut
I hereby authorize _______________________________________________ to release
[name of individual who holds the information]
confidential HIV-related information, as defined in Connecticut General Statute §19a-581, concerning
________________________________________ to the following personnel:
[name of protected individual]
1. School Nurse
2. School Administrator(s)
a. __________________________________
b. __________________________________
3. Student's Teacher(s)
a. ___________________________________
b. ___________________________________
4. Paraprofessional(s)
5. Director of Pupil Personnel Services
6. Other(s)
a. ____________________________________
b. ____________________________________
This authorization shall be valid for:
1. [ ] The student's stay at _____________________________ School
2. [ ] The current school year
3. [ ] Other ____________________________ (specify period)
I provide this information based on my responsibility to consent for the health care of __________________________________________. I understand that such information shall be held confidential by the persons authorized here to receive such information, except as otherwise provided by law.
____________________________________
Name
____________________________________
Relationship to Student
____________________________________
Date