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HIV/AIDS VIRUS ANTIBODY
BLOOD TEST CONSENT FORM
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THIS PAGE DISPLAYS A TYPICAL HIV/AIDS BLOOD TEST CONSENT FORM WITH EXPLANATIONS AND TYPICAL AFFIDAVIT SIGNATURE CERTIFICATIONS.

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Following here is a typical form, representative of the form with which one would be confronted at the time of testing. See Non-continuing form HERE.


INTRODUCTION
Human immunodeficiency virus (HIV) is the cause of acquired immunodeficiency syndrome (AIDS). All persons infected with HIV can spread it to others through unprotected sex, needle sharing, and donating Blood or other tissues. Infected mothers can also spread HIV to newborns. Testing for HIV infection is voluntary. Read this sheet carefully to help you decide whether to be tested or not.

WHAT the TEST MEANS
This test detects antibodies to HIV, not the virus itself. Antibodies are the body's reaction to the virus.

A POSITIVE test means that a person is infected with HIV and can pass it to others. By itself, a positive test does not mean that a person has AIDS, which is the most advanced stage of HIV infection.

A NEGATIVE test means that antibodies to HIV were not detected. This usually means that the person is not infected with HIV. In some cases, however, the infection may have happened too recently for the test to turn positive. The Blood test usually turns positive within 1 month after infection and in almost all cases within 3 months. Therefore, if you were infected very recently, a negative test result could be wrong.

False results (a negative test in someone who is infected, or a positive test in someone who is not infected) are rare. Indeterminate results (when it is unclear whether the test is positive or negative) also are rare. When a test result does not seem to make sense, a repeat test or special confirmatory tests may help to determine whether a person is or is not infected.

BENEFITS of BEING TESTED
There are substantial benefits to being tested. Most infected persons may benefit from medications that delay or prevent AIDS and other serious infections. Test results also can help people make choices about contraception or pregnancy. Therefore, all infected persons should have a complete medical checkup, including tests of the immune system, to help their health care providers recommend the best health care.

There are other reasons to be tested. Even though everyone should follow safer sex guidelines whether or not they are infected with HIV, many persons find that knowing their test results helps them to protect their partners and themselves. Some persons want to know their test results before beginning a new sexual relationship or becoming pregnant. Others will be reassured by learning that they are not infected.

RISKS and DISADVANTAGES of BEING TESTED
Many persons with positive or indeterminate test results will experience stress, anxiety, or depression. Some persons with negative tests may continue or increase unsafe behaviors, which would increase the risk of HIV infection. Some persons are afraid that their test results will get into the wrong hands, and that discrimination might result. (See Privacy and Confidentiality, below.) For these reasons, you should consider your social supports (such as family and friends) and your insurance needs before you are tested.

PRIVACY and CONFIDENTIALITY
We keep a record of the health care services we provide to you. You may ask us to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it from your health care provider.

Washington State law requires that health care providers and laboratories report to the local health department the name of anyone infected with HIV. However, the report is coded and the name is destroyed after 90 days. No lists of names are maintained. Penalties for violations of the confidentiality laws are severe.

Anonymous HIV testing is available. If you do choose to test anonymously, your record will contain only your personal ID code. It will not show your name. To assure that results are provided only to the person who tested, you must confirm your identity with your personal ID code when you return or call for your test results.

OTHER IMPORTANT INFORMATION
In some instances, your test results will be available by telephone. However, if your result is positive, you should return in person to see a counselor.

If your test is positive and you do not call or return to learn the result, we will try to contact you to tell you the result and provide you with appropriate counseling. If your HIV test is positive, persons with whom you have had sex or have shared needles must be informed that they may be infected and that they should be tested for HIV. If you are unable to inform your partner(s) or do not wish to do so, we can do it for you without disclosing your identity.

Pharmacy shelves are stocked with do-it-yourself home tests for Blood glucose, Blood cholesterol paternity tests and pregnancy tests. OraSure Technologies Inc., makes and sells a 20-minute, at-home test that screens for two HIV strains using a swab device that tests saliva, awaiting the FDA.

Your Blood test results, as well as Information about you that we collect at the time of testing, may be used for research purposes. If you agree, we will store a sample of your Blood for possible future use in research (such as evaluating new tests) or to check the quality of our HIV testing methods. Even if your name is in your record, your identity will not be known to the person or persons analyzing the data or preparing materials for publication or public discussion.


CONSENT for HIV TESTING

I have read and understand the above information. I have been advised of the nature of the HIV Blood test; what the results would mean; and the benefits and risks of being tested. I understand that I have the alternative of not being tested. I hereby authorize the Public Health Department to perform this test and to release the results to me.

I do__  do not__  (please check only one) give permission for a portion of my Blood specimen to be stored for possible future testing.
 

____________________ ___________________  ____________
Name or ID of person testing  Signature/Relationship Date

 


CERTIFICATION

I certify that the person named above has been given an opportunity to read the above information and ask questions, that he or she understands the issues discussed, that his or her decision to undergo HIV testing is an informed and voluntary one, and that I have witnessed his or her signature.
   
 

______________________ ____________________  ____________
Public Health Provider Interpreter (if applies) Date



CONSENT and CERTIFICATION for REPEAT TESTS
 

_____________________ ____________________ ____________
Name or ID of person testing  Signature/Relationship Date
_____________________ ___________________  ____________
Name or ID of person testing  Signature/Relationship Date
_____________________ ___________________  ____________
Name or ID of person testing  Signature/Relationship Date
_____________________ ___________________  ____________
Name or ID of person testing  Signature/Relationship Date
     

 


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   last updated 11/10/2005   bloodbook.com