Free Consent HIV Rapid Testing Discordant Results, DPH 42019 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 42019 (12/04)

STATE OF WISCONSIN Page 1 of 2

WRITTEN INFORMED CONSENT FOR ADDITIONAL TESTS FOLLOW-UP ON DISCORDANT RAPID AND CONFIRMATORY TEST RESULTS
Your OraQuick rapid HIV test was reactive and your confirmatory test was either negative or indeterminate. This means that you had test results that were "discordant" or were not the same. In order to understand why this occurred, you are being asked to have additional testing done on your blood, including but not limited to the following medical conditions or factors:
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Hepatitis A Hepatitis B Epstein Barr Rheumatoid Factor

The Wisconsin Division of Public Health and the Centers for Disease Control and Prevention are trying to determine what conditions or factors affect rapid test results. This will help health care providers to understand how to best use the test. To conduct the testing:
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You are being asked to agree to let us test the blood that was taken from you before for confirmatory HIV testing It is recommended that you have a repeat HIV test in one month. When you have your blood test repeated ­ you are being asked to agree to have additional blood taken from you for the testing described above.

Having these tests may benefit you in the following ways:
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You can help find out which individuals are best suited for testing with the rapid HIV test. The results of the tests will be available to you. This may assist you in receiving care for health conditions you may have. If you are concerned that you may have any health conditions, you should discuss this with your regular health care provider.

Possible risks of these tests:
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There may be some discomfort or bruising from having your blood taken from your arm. There is a risk of introducing infection while drawing blood, even though the needle used to collect your blood is sterile.

If you give your name and contact information, you can usually receive these test results in 3 to 4 weeks. Your name and contact information will not be used for any other purpose than to provide you your results. If you decide to provide blood samples anonymously (without your name), these test results will not be available to you because your identity will not be linked to a specimen or test result . Your decision not to provide blood samples for further testing will not affect your relationship with our organization or your access to our services in the future.

DPH 42019 (12/04)

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Confidentiality: Your blood will be sent to the Centers for Disease Control and Prevention with a unique identifier number ­ not your name. This clinic will keep a copy of your consent in your record. Your results for the tests will be made available to you if you provide your contact information. We will schedule a follow-up appointment at this clinic for you to receive these test results. If you choose to test anonymously and not provide any contact information, we will be unable to return your test results. No other agency or organization will have access to the test results without your consent.

Statement of Consent: I agree to have blood that was taken from me before for confirmatory HIV testing to be tested for the conditions or factors listed above. I agree to have my blood drawn for additional testing when I have my repeat HIV test. I will get results of laboratory tests back in three to four weeks. I have read the above information. I understand the reasons for providing additional blood specimens. I have had the opportunity to ask questions. All my questions have been answered to my satisfaction. I understand that providing these specimens is voluntary and declining to do so involves no penalty or loss of benefits to me. Knowing all of this, I agree to have my blood tested as indicated in this consent.
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Signature Address City Witness If anonymous: Anonymous Code Witness State Zip

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Telephone Date

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For questions: Contact Kathleen Krchnavek at the Wisconsin Division of Public Health at (608) 267-3583 or by e-mail at [email protected].