*Source Individual’s Consent or Refusal Form for HIV, HBV and HCV Infectivity Testing
*This person’s blood or body fluids provided the source of this exposure.
NOTE: Print this form and distribute copies of this form to: □ Health Care Professional □ WSU HR 1016
Exposed Source Individual's Statement of Understanding
I understand that employers are required by law to attempt to obtain consent for HIV, HBV, and HCV infectivity testing each time an employee is exposed to the blood or bodily fluids of any individual. I understand that a WSU employee or student intern has been accidentally exposed to my blood or bodily fluids and that testing for HIV, HBV, and HCV infectivity is requested. I am not required to give my consent, but if I do, my blood will be tested for these viruses at no expense to me.
I have been informed that the test to detect whether or not I have HIV antibodies is not completely reliable. This test can produce a false positive result when an HIV antibody is not present and that follow-up tests may be required.
I understand that the results of these tests will be kept confidential and will only be released to medical personnel directly responsible for my care and treatment, to the exposed healthcare worker for his or her medical benefit only and to others only as required by law.
For More Information
Contact WSU’s Human Resources 3850 Dixon Parkway Dept 1016 Ogden, Utah 84408-1016 Telephone: (801) 626-6184, Fax: (801) 626-6925.
Please note: For "Location" below, type a name or address to search buildings and outdoor areas on campus. If off campus, select "Off Campus" for "Campus, Building, or Outdoor Area."