Northfield Board of Education file code: 4112.4/4212.4
Exhibit B X Other Reasons
Northfield Public School District
2000 New Road
Northfield, NJ 08225
RELEASE OF INFORMATION FOR POST-EXPOSURE MANAGEMENT
RE: Exposure to blood or other potentially infectious materials
Pursuant to our discussion on the telephone, a staff person or student in our school has been exposed to your child’s blood or other body fluid. As a result, we have received a request, from the health-care provider listed below, for information about your child. The school would like to give this health-care provider your child’s name and your name, address and telephone number so that he/she can contact you directly to obtain the requested information. Since your consent is necessary for this type of disclosure, please complete and return this form to my attention at the school’s address if you authorize this release of information. Thank you.
Name: _________________________________________ D.O.B.: ___________________
(Student/Infant/Toddler: circle one)
Parent/Legal Guardian Information:
I hereby give consent to the Northfield Public School District to release the above information to:
______________________________________ (Name of Health-Care Provider making request).
As the parent/legal guardian of the above-named child, I authorize, by my signature below, the release of this information.
Signature of Parent/Legal Guardian Date