Bentuk Informed Consent
Bentuk Informed Consent
Bentuk Informed Consent
Before you receive an HIV antibody test, you must give your consent. This form explains the test and how the test results can be used.
It should help you decide whether you want to take the test. Please read it carefully. Your doctor or HIV tester must go over this
information with you. If you have any questions, ask them. Please read all this information before you decide to be tested. If you want
to be tested, please sign the back of this form.
If you want to take the test, you dont have to let anyone know your test result. You dont even have to tell anyone you've taken the
test. You can find a testing site near you by calling Infoline at 211 or 1-800-203-1234 within Connecticut.
How can I get more information about the test and my rights?
If you have more questions about the test, please ask your doctor or call your local health department. If you have questions about
your rights, contact the Connecticut Commission on Human Rights & Opportunities at (860) 541-3400.
All these people are also required by state law to keep your result private. You can ask your doctor or health care provider if your HIV
test result has been released to anyone.
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I have read all of this form or it has been read to me, and Ive discussed it with my doctor or test counselor. I have been told about the
nature of HIV and AIDS and have been told about how the virus may be passed from one person to another. I understand that testing
HIV positive in Connecticut is reportable to the state health department and that if I test positive, the HIV tester will be reported by
name. If I do not return for my test result, the test counselor will still report the result to the state health department.
__________________________________________________________________ ___________________________________
Name of person who will be tested Date of birth
__________________________________________________________________ ___________________________________
Signature of person who will be tested or person authorized to consent for person Date
If someone other than the person to be tested has signed, give name and address of person signing and relationship to person to be
tested. If necessary, explain why the person to be tested did not sign.
___________________________________________________________________________________________________________
I have provided to the person who signed this form an explanation of the nature of HIV and AIDS, information about behaviors
known to pose risks for transmission of HIV infection, and discussed and answered any questions about the information covered in
this form.
__________________________________________________________________
Name of clinician or HIV tester
__________________________________________________________________ ___________________________________
Signature of clinician or HIV tester Date
Informed Consent-Eng (December 2014)