Consent Form Hiv Test Page 20
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42RESIDENT’S NAME & NUMBER ________________________________________________________
DATE/
DATE/
DATE/
DATE/
DATE/
DATE/
EDUCATION
INITIALS
INITIALS
INITIALS
INITIALS
INITIALS
INITIALS
HIV/AIDS/STD*
Sexual Conduct/Behavior*
Family Planning/Birth Control*
HIV Pre-Test Counseling
HIV Post-Test Counseling
Medication Education
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
DATE/
DATE/
DATE/
DATE/
DATE/
DATE/
EDUCATION
INITIALS
INITIALS
INITIALS
INITIALS
INITIALS
INITIALS
HIV/AIDS/STD*
Sexual Conduct/Behavior*
Family Planning/Birth Control*
HIV Pre-Test Counseling
HIV Post-Test Counseling
Medication Education
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
DATE/
DATE/
DATE/
DATE/
DATE/
DATE/
EDUCATION
INITIALS
INITIALS
INITIALS
INITIALS
INITIALS
INITIALS
HIV/AIDS/STD*
Sexual Conduct/Behavior*
Family Planning/Birth Control*
HIV Pre-Test Counseling
HIV Post-Test Counseling
Medication Education
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
* Components of Human Sexuality Training (admission within 60 days and annually) in accordance with FSHOP 155-2,
Human Sexuality. Initial and date when component complete. If education is offered and resident refuses, document in
progress notes and re-offer education every thirty days. Date of completion, refusal, and or exclusion is input into the
computer data base.
*** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY ***
FLORIDA STATE HOSPITAL, CHATTAHOOCHEE, FL 32324
IMMUNIZATION/TREATMENT RECORD
Form 13, (Revised) Mar 01
FLORIDA STATE HOSPITAL
Office of Primary Responsibility: Health Care Services Medical Service Director
COMMUNICABLE DISEASES/
Attachment 4
EDUCATION FORM
Page 2 of 2
Page 2 of 2
Operating Procedure 153-31
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