Section 697.APPENDIX A Sample HIV Testing Forms

Section 697.ILLUSTRATION A Sample Written Informed Consent for HIV Antibody Testing

WRITTEN INFORMED CONSENT FOR HIV ANTIBODY TESTING

(Conventional Testing − Not for Use with a Rapid HIV Test)

Test Subject or Number:		Date:
		Time:		(AM)(PM)

I hereby grant my permission for a test to detect whether I have antibodies to HIV (Human Immunodeficiency Virus) in my body.

HIV Testing is voluntary and requires your consent in writing. The purpose of HIV antibody testing is to show whether you are infected with HIV, the virus that causes AIDS.

Any test result that indicates that antibodies for HIV are present is considered positive for HIV infection.

Before you consent to be tested for HIV, your healthcare provider should speak to you about:

§ How HIV is passed from person to person and mother to baby;

§ Steps to take that may prevent the transmission of HIV; and

§ The meaning of an HIV antibody test result.

If you agree with the following statements and want to consent to HIV testing, please sign this form.

I have been counseled about the benefits of having an HIV test and understand that:

§ Human immunodeficiency virus (HIV) is the virus that causes AIDS;

§ HIV is spread by sexual intercourse, so all sexually active persons are potentially at risk for HIV infection;

§ HIV is spread by sharing needles with another person during injection of drugs, so all injection drug users are potentially at risk for HIV infection;

§ HIV can be passed from a mother to her baby during pregnancy, at delivery, and through breastfeeding; and

§ HIV antibody test results are confidential, and the law protects me from discrimination.

I understand that a positive result does not mean I have AIDS, but indicates that I have HIV infection. I understand that if my test results are positive, I will be offered HIV counseling.

I understand that test results may indicate that a person has HIV antibodies when the person does not have the antibodies (a false positive result) or the test may fail to detect that a person has antibodies to the virus when the person does in fact have these antibodies (a false negative result).

If my HIV antibody test result is negative, no further testing will be done at this time. A negative HIV antibody test result most likely means that I am not infected with HIV, but it may not detect recent infection.

If my HIV antibody test result is positive, this means that antibodies to the virus were detected and that I am HIV infected.

Confidentiality of HIV Information:

If you take the HIV test, your test results are confidential. Under Illinois law, confidential HIV information can be given only to people to whom you allow it to be given by your written approval, to people who need to know your HIV status in order to provide medical care and services, including: an authorized agent or employee of a health facility or a healthcare provider if the health facility or provider is authorized to obtain test results; those who are exposed to blood/body fluids in the course of their employment; and organizations that review the services you receive.

The law also allows your confirmed HIV test results to be released: to public health officials as required by law; for payment for care and treatment; to a temporary caretaker of children taken into protective custody by the Illinois Department of Children and Family Services; and to any other entity permitted by the AIDS Confidentiality Act.

I understand that my test results will be kept confidential to the extent provided by law. In addition, I understand that I may withdraw from the testing at any point in time prior to the completion of laboratory tests. I understand that my testing is voluntary.

I agree to be tested and I agree that I may be told my test results.

I agree that if the result of my HIV test is positive I may be referred to another healthcare provider for follow-up testing and care.

I have been advised about the purpose, potential uses, limitations and meaning of the test results; the voluntary nature of the test; the right to withdraw consent at any time prior to the completion of laboratory tests; and the confidentiality protections under the law. The information presented above has been completely and clearly explained to me, and all of my questions have been answered. I hereby authorize my physician or facility to collect an oral or blood specimen and perform an HIV antibody test on that specimen.

	Patient/Client Signature or Signature of Legally Authorized Representative
	Date
	Facility/Provider Witness
	Date

(Source: Amended at 30 Ill. Reg. 2373, effective February 3, 2006)