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Auburn University Harrison School of Pharmacy Post-exposure Consent for Testing Source patient Testing for HIV HBV and HCV Infectivity This form should be reviewed and signed by the source patient and provided to the health care provider responsible for the post-exposure evaluation. Exposed Individual s Information Name Please Print Contact Number Exposure Date Source Patient Statement of Understanding I understand that my consent is required by law for HIV hepatitis B HBV and hepatitis C HCV infectivity testing if someone is exposed to my blood or bodily fluids. I understand that a student pharmacist or faculty member of the Auburn University Harrison School of Pharmacy has been accidentally exposed to my blood or bodily fluids and that testing for HIV HBV and 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 health care provider responsible for the exposed student pharmacist or faculty member to ensure appropriate medical evaluation and care and to others only as required by law. Consent or Refusal I consent to HIV Testing Hepatitis B Testing I refuse consent to Source Individual Identification Source patient s printed name Relationship if signed by someone other than the source patient Date signed. I understand that a student pharmacist or faculty member of the Auburn University Harrison School of Pharmacy has been accidentally exposed to my blood or bodily fluids and that testing for HIV HBV and 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. 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 health care provider responsible for the exposed student pharmacist or faculty member to ensure appropriate medical evaluation and care and to others only as required by law. 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 health care provider responsible for the exposed student pharmacist or faculty member to ensure appropriate medical evaluation and care and to others only as required by law. Consent or Refusal I consent to HIV Testing Hepatitis B Testing I refuse consent to Source Individual Identification Source patient s printed name Relationship if signed by someone other than the source patient Date signed..

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