Informed Consent And Agreement To Hiv Testing
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2Informed Consent and Agreement to HIV Testing
I understand the following information, which I have read or has been read to me:
•
Blood, or another body fluid or tissue sample, will be tested for human immunodeficiency virus (HIV) infection;
•
Consent to be tested for HIV, the virus that causes AIDS, should be given FREELY;
•
Results of this test, like all medical records, are confidential, but confidentiality cannot be guaranteed; and
•
If positive test results become known, an individual may experience discrimination from family or friends and at school
or work.
What a NEGATIVE Result Means:
•
A negative test means that HIV infection has not been found at the time of the test.
What a POSITIVE Result Means:
•
A positive HIV test means that a person is infected with HIV and can transmit the virus by having sex, sharing
needles, childbearing (from mother to child), breastfeeding, or donating organs, blood, plasma, tissue, or breast milk.
•
A positive HIV test DOES NOT mean a diagnosis of AIDS -- other tests are needed.
What Will Happen if the Test Is Positive:
•
A copy of the Department of Health and Mental Hygiene's publication "Information for HIV Infected Persons" will be
provided;
•
The health department or my doctor will offer advice about services that are available;
•
Women who are pregnant or may become pregnant will be told of treatment options which may reduce the risk of
transmitting HIV to the unborn child;
•
Information will be provided on how to keep from transmitting HIV infection;
•
My name will be reported to the health department for tests that indicate HIV infection. This includes, but is not limited
to: HIV Antibody (Western blot), HIV Viral Load (RNA or DNA quantification), HIV viral sequencing or HIV p24 antigen
tests;
•
My name will be reported to the health department if my doctor finds that I have AIDS;
•
I will be offered assistance in notifying and referring my partners for services. If I refuse to notify my partners, a doctor
may notify them or have a representative of the local health department do so. If a representative of the local health
department notifies my partners, my name will not be used. Maryland law requires that when a local health
department knows of my partners, it must refer them for care, support, and treatment.
I have been given a chance to have my questions about this test answered.
I hereby agree to be tested for HIV infection.
Print name of individual to be tested in the boxes below:
First Name
Middle Init.
Last Name
Signature of Individual to be Tested
Date
(or Authorized Substitute )
Signature of Counselor or Health Care Provider
Date
State of Maryland - DHMH AIDS Administration
Form 4667 (revised 5/2007)
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