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NYU SoM IRB HRPP
Institutional Review Board
Human Research Protection Program
1 Park Avenue | 6th Floor | New York, NY 10016
http://irb.med.nyu.edu
NEW YORK STATE DEPARTMENT OF HEALTH
Informed Consent to Perform an HIV Test and Release HIV Information Form
1. Testing for HIV Infection/Testing Methods:
There are a number of tests that can be done to show if you are infected with HIV, the virus that causes AIDS. Your
provider or counselor can provide specific information on these tests. These tests involve collecting and testing blood,
urine or oral fluid. The most common test for HIV is the anti-body test.
The HIV antibody test is a blood test. The test shows if you have antibodies to the virus that causes AIDS. A sample of
your blood will be taken from your arm with a needle. If the first test shows that you have antibodies, a different test will
then be done on the same blood sample to make sure the first test was right. A positive test result means that you have
been exposed to the virus and are infected. It does not mean that you have AIDS or that you will become sick with AIDS
in the future. A negative test means that you are probably not infected with the virus. It takes the body time to produce HIV
antibodies. If you have been exposed to HIV recently, you need to be retested in several months to make sure you are not
infected. Your doctor or counselor will explain this to you.
2. Meaning of HIV Test Results?
A negative test result on the HIV antibody test most likely means that you are not infected with HIV, but it may not show
recent infection. If you think you have been exposed to HIV, you should take the test again three months after the last
possible exposure.
A positive result on the test means that you are infected with HIV and can infect others.
Sometimes the HIV antibody test result is not clearly positive or negative, or may be a preliminary result. Your provider or
counselor will explain this result, and may ask that you give you consent for further testing.
3. What are the benefits of taking the test?
If you test negative: you can learn how to protect yourself from getting infected with the virus in the future. Ask your
doctor or counselor how.
If you test positive:
 You can learn how to avoid giving the virus to others.
 Knowing that you are infected is important for your health. Your doctor can care for you better.
 If you are a woman or man who is thinking of having a child, you can learn about the risk of passing the virus to
your baby.
 If you are a woman who is already pregnant, your doctor can provide information on the full range of options and
services available to you.
4. Confidentiality of HIV Information:
If you take the HIV antibody test your test results are confidential. Under New York State Law, confidential HIV
information can only be given to people you allow to have it by giving your written approval, or to people who need to
know your HIV status in order to provide medial care and services, including: medical care providers; persons involved
with foster care or adoption; parents and guardians who consent to care of minors; jail, prison, probation and parole
employees; emergency response workers and other workers in hospitals, other regulated settings or medical offices, 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 you HIV information to be released under limited circumstances: by special court order; to
public health officials as required by law; and to insurers if necessary to pay for care and treatment.
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5. Reporting Requirements:
Your name will be reported to the health department if you have a confirmed positive HIV antibody test result received
through a confidential test, other HIV related test results, a diagnosis of AIDS, or if you have chosen to attach your name
to a positive test result at an anonymous site. The health department will use this information to track the epidemic and to
better plan prevention, health care and other services.
6. Notifying Partners:
If you test positive, your provider will talk with you about the importance and benefits of notifying your partners of their
possible exposure to HIV. It is important that your partners know they may have been exposed to HIV so they can find
out whether they are infected and benefit from early diagnosis and treatment. Your provider may ask you to provide the
names of your partners, and whether it is safe for you if they are notified. If you have been in an abusive relationship with
on of these partners; it is important to share information with your provider. For information regarding services related to
domestic violence, call 1-800-942-6906.

Under state law, you provider is required to report to the health department the names of any of your partners
(present and past sexual partners, including spouses, and needle sharing partners whom they know).

Several options are available to assist you and your provider in notifying partners. If you or your provider does
not have a plan to notify you partners, the Health Department may notify them without revealing your identity. If
this notification presents risk of harm to you, the Health Department may defer the notification for a period of time
sufficient to allow you to access domestic violence prevention services.

If you do not name any partners to your provider or if a need exists to confirm information about your partners, the
health department may contact you to request your cooperation in this process.
7. Voluntary Testing:
Taking an HIV antibody test is voluntary. You do not have to take the test. If you do not wish anyone to know your test
results or even that you have been tested, you can go to an anonymous test site. This is a place where you can receive
counseling and the HIV test without giving your name or address. You can find the nearest anonymous test site by calling
the AIDS hotline at 1-800-541-2437.
8. Confidentiality of Test Results
If you feel your confidentiality has been broken, or for more information about HIV confidentiality, call the New York State
Department of Health HIV Confidentiality Hotline at 1-800-962-5065. Any health or social service provider who illegally
tells anyone about your HIV information may be punished by a fine of up to $5000 and jail term of up to one year. The law
also protects you from HIV related discrimination in housing, employment, health care or other services. For more
information, call the New York State Division of Human Rights at 1-800-523-2437.
If you take the HIV antibody test, your test results are confidential. Under the New York State Law, confidential HIV
related information can only be given to people you allow to have it by signing a release form, or the persons listed below
on this form.**
9. Risks Involved with Disclosure and Sources of Help
If you test positive, you should be careful about telling others what your test showed. Some HIV positive people have
been discriminated against by employers, landlords and others. If you experience discrimination because of release of
HIV related information you may contact the New York State Division of Human Rights at (212) 870-8624 or the New York
City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.
10. For More Information
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If you have further questions about informed consent to HIV antibody testing, you may contact the New York State
Department of Health at (518) 486-1595.
* Human Immunodeficiency Virus that causes AIDS.
See below for a list of persons who can receive HIV related information. **
My questions about the HIV test have been answered. I agree to take the HIV antibody
test.
Signature of person who will be tested
Signature of person authorized to consent for person to be tested
Date
Date
Name of person who will be tested (please Print)
Name of person authorized to consent (Please Print)
I have explained the means by which the HIV antibody test is done, the meaning of the results and the possible
consequences of disclosing of the test results to the individual above, and have answered any questions she/he had
about the test.
Name:
11. Under New York State Law. HIV related information is confidential and may only be given:
a.
To you (or a person authorized by law who consented to the test for you):
b.
To anyone whom you have specifically authorized to receive such information by
signing a written release:
c.
To a health care facility (such as a hospital, blood bank, or clinical laboratory) or
a health care provider (such as a physician, nurse, or mental counselor) providing
care to you or your child, and anyone working for such a facility or provider who
reasonably needs the information to supervise, monitor, or administer a health
service;
d.
To a person who your doctor believes is at a significant risk for HIV infection, if
you do not notify that person after being counseled to do so;
e.
To committee or organization responsible for reviewing or monitoring a health facility.
f.
To a federal, state, county, or local health officer when the state or federal law
requires disclosure;
g.
To government agency, when the agency needs the information to supervise,
monitor or administer a health or social service;
h.
To an authorized foster care or adoption agency;
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i.
To insurance companies and other third party payers such as Medicaid if
necessary for the payment of services to you;
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j.
To any person to whom a court orders disclosure under limited circumstances set
forth by law. Except in an emergency situation, advance notice and an opportunity to
oppose the release of such information would be given to you;
k.
To the Division of Parole, the Division of Probation, the Commission of Correction, or a medical director of a local
correctional facility, as permitted by HIV confidentiality regulations of such organization.
I.
By a physician to the person, who consents for your health care (parent, guardian,
etc.) if disclosure is necessary to provide timely care for you, and you have been
counseled regarding the need for disclosure. A physician may not disclose such
information if it is against your best interest to do so.
12. SPECIAL CONDITIONS
You can ask your doctor if HIV related information about you has been released to anyone listed above. Despite the fact
that New York State Law provides that certain persons or agencies may receive confidential HIV information without you
specific consent, the researchers conducting this study and NYU Medical Center will not release confidential HIV
information derived from this research study except as follows:
1) to persons whom you specifically authorize in writing to receive it
2) to parties to whom disclosure is compelled by court order; and
3) if the confidential HIV information is obtained in a treatment setting it may become part of your confidential
medical record, in which case, it will be maintained as confidential in accordance with laws for the confidentiality'
of patient medical records as stated above.
(HIV = Human Immunodeficiency Virus)
New York State Department of Health AIDS Institute
13. Authorization for Release of Confidential HIV* Related Information.
Confidential HIV Related Information is any information indicating that a person had a HIV related test, or has HIV
infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed
to HIV. Under the New York State Law, except for certain people, confidential HIV related information can only be given to
persons you allow to have it by signing a release. You can ask for a list of people who can be given confidential HIV
related information without a release form, Despite the fact that New York State Law provides that certain persons or
agencies may receive confidential HIV information without your specific consent, the researchers conducting this study
and NYUMC will not release confidential HIV information derived from this research study except as follows:
1) To persons whom you specifically authorize in writing to receive it.
2) To parties to whom disclosure is compelled by court order, and
3) if the confidential HIV information is obtained in a treatment setting, it may become part of your confidential
medical record, in which case, it will be maintained as confidential in accordance with laws for the confidentiality
of patient medical records as stated above.
If you sign this form, HIV related information can be given to the people listed on this form, and for the reason(s) listed on
the form. Any confidential information disclosed to the persons named below will be marked confidential and will bear a
warning that the information may not be further disclosed.
If you experience discrimination because of release of HIV related information, you may contact the New York State
Division of Human Rights at (212) 870-8624 or the New York City Commission of Human Rights at (212) 566-5493. These
agencies are responsible for protecting your rights.
Name and address of facility/provider obtaining release:
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Name of person whose HIV related information will be released:
Name and address of person signing this form: (if other than above):
Relationship to person whose HIV information will be released:
Name and address of person who will be given HIV related information:
Reason for release of HIV related information:
Validation of research results by research sponsor and/or FDA
Delivery to a cooperating researcher
Other—Specify
Time during which release is authorized: From:
To:
My questions about this form have been answered. I know that I do not have to allow
release of HIV related information, and that I can change my mind at any time.
Signature
Date
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