Section 699.APPENDIX A Sample Rapid HIV Testing Forms

Section 699.ILLUSTRATION A Sample Written Refusal Form for Testing Newborn Infants

WRITTEN REFUSAL OF RAPID HIV ANTIBODY TESTING

FOR A NEWBORN INFANT

Test Subject or Number:				Date:
				Time:

As a parent or legal guardian of a newborn infant, I am not giving my permission for a Food and Drug Administration (FDA) approved test to detect whether my newborn infant has antibodies to HIV (human immunodeficiency virus).

I understand that:

The human immunodeficiency virus (HIV) is the virus that causes AIDS.

One way in which HIV is spread is by sexual intercourse, so all sexually active women are potentially at risk for HIV infection.

HIV can be passed from a mother to her baby during pregnancy, at delivery, and through breastfeeding.

If I have HIV, it is a serious illness that can affect my health and the health of my baby.

HIV antibody test results are confidential.

I have been counseled about HIV, including:

The potential benefit of HIV testing for my newborn infant, including interventions to prevent transmission of infection from mother to baby;

Information about HIV infection and HIV transmission;

Information about the meaning of the HIV test and the test results;

The side effects of interventions to prevent HIV transmission;

Information about the availability of referrals and further counseling;

The voluntary nature of the HIV testing, including the opportunity to refuse, in writing, testing of the newborn infant; and

The confidentiality provisions that relate to HIV/AIDS testing.

I understand that I can refuse HIV testing of my newborn infant. I understand that testing should occur immediately after birth, but no later than 48 hours after birth. I understand that if my newborn infant receives medication no later than 48 hours after birth, the risk of transmission of HIV would be lowered. I understand that delaying testing to a later time will reduce or eliminate the chance that medication can be used to prevent my baby from becoming HIV infected.

I understand that I have received a fair explanation of:

The HIV test procedures to be followed;

My right to withdraw my consent to an HIV test at any time;

The right to anonymity to the extent provided by law with respect to participation in the HIV test and disclosure of test results, and the right to keep confidential information that identifies the subject of the HIV test and the test results.

I understand that if my newborn infant is tested for HIV, the results of the tests are placed in my newborn infant's record and reported to his/her health care provider, and positive results are reported to the Illinois Department of Public Health. Under Illinois law, confidential HIV information can be given only to people to whom I allow it to be given by my written approval, or to people who need to know my newborn infant's HIV status in order to provide medical care and services, including an authorized agent or employee of a health facility or health care provider, if the health facility or provider is authorized to obtain test results; those who are exposed to my newborn infant's blood/body fluids in the course of their employment; and organizations that review the health care services I receive. The law also allows my newborn infant's HIV information to be released under certain limited circumstances to persons whom I may designate through an authorization, to my legal representative, to my spouse, to the parent of the child, to public health officials as required by law, for payment for care and treatment, and as required for a temporary caretaker of a child taken into protective custody by the Department of Children and Family Services. The results also will be provided to the State and local health department to use this information to track the disease and to better plan prevention, health care, and other services.

I understand and agree that my REFUSAL of testing will be placed in my medical record. In addition, I understand that I may withdraw my REFUSAL of HIV testing for my newborn infant at any point in time.

I understand that HIV may be transmitted from me to my newborn infant during labor and delivery. I understand that if I refuse HIV testing for my newborn infant, he/she will not be able to promptly receive medication that lowers the risk of his/her becoming HIV infected. I understand that if HIV has already been transmitted to my child, not performing the test means he/she will not receive proper treatment. Delaying testing to a later time will reduce or eliminate the chance that medication can be used to prevent my child from becoming HIV infected. I understand that HIV infection causes serious illnesses and these illnesses could result in my newborn's death.

With the information presented above having been completely and clearly explained to me, and all of my questions having been answered, I refuse to authorize testing of my newborn infant for HIV.

Patient/Client Signature or Signature of Legally Authorized Representative
Date
Health Care Professional/Facility Witness
Date