(Hiv) Antibody Test Consent Form (Rapid Testing) printable pdf download

Human Immunodeficiency Virus (HIV) Antibody Test

Consent Form (Rapid Testing)

(Confidential and Anonymous Testing)

When infected with HIV, the body produces proteins called antibodies. This test is looking for those antibodies. This

is not a test for AIDS – only a doctor can make that diagnosis.

I understand a rapid test will be performed which will use a specimen from a drop of blood from my finger, a swab

from the inside of my mouth, or from blood drawn from my arm.

I understand I will receive a test result today.

If I receive a Negative test result it means that I am not at this time HIV infected. Although, since it

takes time for antibodies to develop, I will have to take another test if I was exposed within the last 3-6

months.

If I receive a Preliminary Positive test result it means there is a very good possibility that I am infected

with HIV. It also means I would need to have blood drawn from my arm and/or a drop of blood from my

finger for a second test. This is the best way of making sure the information given to me is accurate. If

blood is drawn from my arm, it will be sent to a laboratory and I will need to return to the clinic in about

2-3 days to receive the result. If a drop of blood is taken from my finger to perform a second rapid test, I

will receive the result in about 20 minutes.

I understand that I have a choice regarding how I test.

If I test confidentially, I will sign my name and provide my address and telephone number on this form.

This is the best way for me to enter into treatment, if necessary, and to learn of other services. It is also

a way for someone to reach me if I do not return to receive a confirmatory result.

If I test anonymously, I will sign this form as John/Jane Doe. This means no one will be able to reach

me if I do not return for my confirmatory result. In addition, no one can reach me to provide me with

other services I might need.

Whether I test confidentially or anonymously, I will get a coded number. The coded number will be placed on this

consent form and on all the testing materials. If a confirmatory test is necessary the same coded number will be

placed on the tube of blood and on the laboratory slip that will be sent to the laboratory. All records in this clinic are

maintained as confidential and kept under lock and key.

I understand that if I receive a second positive test result, it will be reported to the New Jersey Department of Health

as required by law. Any other release of this information will require my written consent, a court order, or a

subpoena.

I have read or someone has read this form to me. A counselor has answered all of my questions and I have decided

to test for HIV. I will give my permission to test by signing the form below.

___________________________________

(Signature of Witness)

(Signature of Client or Guardian)

___________________________________

(Coded Number)

(Client’s Street Address)

___________________________________

(Date)

(City and State)

___________________________________

(Telephone Number)

CT-28

JUL 12

(Hiv) Antibody Test Consent Form (Rapid Testing)

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