MEDICAL RECORD 
INFORMED CONSENT STATEMENT FOR HIV BLOOD TESTING 
We request your permission to test your blood for the presence of antibodies to the Human 
Immunodeficiency Virus (HIV), the virus that causes Acquired Immune Deficiency Syndrome (AIDS). In order to 
perform the test, a small amount of blood (approximately 2 teaspoons) will be withdrawn from one of your 
arms with a needle. You may experience some slight discomfort at the needle entry site and there may be 
some bruising. In addition, there is a very small risk of your fainting or of infection at the needle entry site. If 
, your test results are found to be positive, or if you are otherwise diagnosed as having AIDS, you should be 
aware of the following Clinical Center HIV Testing Policy: 
1. Your physician will notify you promptly of the HIV test results. 
2. Your physician and/or the Clinical Center HIV counselor will offer you, and any current and/or ongoing 
sexual partner(s) (spouses are generally considered to be current or ongoing sexual partners) or needle- 
sharing partner(s) you identify, information on the meaning of the test results and how to prevent the 
spread of the infection. 
3. Because the virus may be transmitted in several ways, it is important that you inform sexual and/or 
needle-sharing partner(s) that any, or all, of them may have been exposed to the HIV virus and 
encourage them to be tested. If you request it, staff at the Clinical Center will assist you in notifying 
your partner(s) and arrange counseling for them through an HIV counselor. 
4. The results of your HIV test and/or documentation of the diagnosis of AIDS will become a part of your 
Clinical Center medical record and, as such, will be protected from unauthorized disclosure by the 
Federal Privacy Act of 1974. In general, access to your medical record will be restricted to those health 
care professionals directly involved in your care or in the conduct of ongoing biomedical research, and 
information is not usually released to other third parties without your permission or that of your 
designated representative. However, there are some particular routine uses of such information of 
which you should be aware. 
a. If you are unwilling or unable to notify your partner(s), the Clinical Center is responsible for 
attempting to contact and inform them of their possible exposure to the virus. Reasonable attempts 
will be made to protect your identity including withholding your name when notifying any partner(s) 
of their possible exposure. Some notification or counseling of current and/or ongoing partners may 
be carried out through arrangements with, or referral to, local public health agencies. 
b. A summary of your care at the Clinical Center will be sent to the physician who referred you here 
\ for treatment. 
c. The Clinical Center may report certain communicable diseases, including AIDS and symptomatic 
HIV infection, to appropriate State and Federal government agencies. 
If you have any questions regarding the HIV testing or the information provided above, you are encouraged to 
discuss them with your physician and/or a Clinical Center HIV counselor (496-2381). 
Complete Appropriate Item Below, A or B: 
4. Adult Patient’s Consent: 'I have read the explanation 
9bout the blood testing and have been given the 
opportunity to discuss it and to ask questions. I 
oereby consent to take part in this blood testing. 
B. Parent’s Permission for Minor Patient: I have read 
the explanation about the blood testing and have 
been given the opportunity to discuss it and to ask 
questions. I hereby give permission for my child to 
take part in this blood testing. 
ft; 
signature of Adult Patient 
Signature of Witness 
Date 
Date 
Signature of Parent(s) 
Date 
(If Other than Parent, Specify Relationship) 
Signature of Witness 
Date 
Recombinant DNA Research, Volume 15 
NIH-2663 (2-90) 
, PA. 09 - 25-0099 
[849] 
