I further understand that a positive blood test result for HIV does not mean that I have AIDS, but that my blood has been exposed to the AIDS virus and antibodies to that virus are present in my blood. I understand that in the event of a positive test result there are other recommended confirmatory tests that are available if I do so desire.

I have also been informed and understand that the test results, in a percentage of cases, may indicate that a person has antibodies to the virus when the person does not (a false positive result) or that 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).

I understand that I have the right to anonymity in the test, if requested.

I understand that if there is a positive test result, such result must be reported to the Department of Public Health. I further understand that no additional release of the results will be made without my written authorization and the results will be kept confidential to the extent provided by law.

I understand that I am to be tested at the time of exposure and tested again at 6 weeks, 3 months, 6 months and 12 months after exposure.

I understand that I may withdraw from the testing at any point in time prior to the completion of laboratory tests, and I hereby state that my agreement to be tested is voluntary on my part and has not been obtained through any undue inducement, threat, or coercion.

It is with the above understanding that I hereby give my consent to the testing of my blood.

Date:

Signature:

Social Security #:

Printed name:

Witness:

I decline testing:

Date:

Signature:

Social Security #:

Printed name:

Witness: