Sample Hiv Test Results Form printable pdf download

Name and Address of Agency which Holds the Limited Test Site Permit”

Rapid HIV Antibody Test Result

Client Name/ID # ___________________ Collection Date: ___/___/_____

Tester Initials:_______

Clients Date of Birth: ___/___/____

Race: ___________ Gender:_________

Name of Authorizing Physician_______ _____________________________________

The HIV-1/2 antibody result from the Rapid HIV Antibody Test is:

Non-Reactive

Reactive

(Negative)

(Preliminary Positive)

Invalid

❑

Type of Specimen:

Rapid test, finger stick with whole blood

❑

Oral Fluid Specimen

Meaning of the test result:

A non-reactive (negative) test result means that no antibodies to HIV-1 have been

detected. HIV antibodies may be absent during the “window period” of infection.

Follow-up testing may be necessary if indicated by risk factors.

A reactive (preliminary positive) test result suggests that antibodies to HIV-1 may be

present in the blood obtained from a rapid, finger stick test with whole blood. A

specimen will have to be sent to a laboratory for a Western Blot test prior to confirmation

of the reactive test result. Precautions should be taken to avoid the chance of spreading

HIV.

An invalid test result resulting from a rapid finger stick can be due to a problem running

the test or an interfering substance in the specimen. A specimen using other testing

technology should be collected and submitted to a laboratory for HIV testing.

Questions: If you have any questions about the rapid test result, please contact the

Authorizing Physician.

Confidentiality and Disclosure:

This information has been disclosed to you from confidential records which are protected

by state law. State law prohibits you from making any further disclosure of this

information without the specific written consent of the person to whom it pertains, or as

otherwise permitted by law.

Sample 2012

Sample Hiv Test Results Form