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r <br /> Infection <br /> Source Individual's Consent or Refusal Form <br /> For HIV, HBV, and HCV Infectivity <br /> Source Individual is the person whose blood or bodily fluids provided the source of exposure. <br /> Exposed individual information: <br /> Name: <br /> Address: <br /> Phone number: <br /> Exposure date: <br /> Source Individuals Statement of Understanding: <br /> I understand that employers are required by law to attempt to obtain consent for HIV, HBV and <br /> HCV infectivity testing each time an employee is exposed to the blood or bodily fluids of any <br /> individual. I understand that a body art practitioner has been accidentally exposed to my blood <br /> and that testing for HIV, HBV and HCV infectivity is requested. I am not required to give my <br /> consent, but if I do, my blood will be tested for these viruses at no expense to me. <br /> I have been informed that the test to detect whether or not I have HIV antibodies is not <br /> completely reliable. This test can produce a false positive result when an HIV antibody is not <br /> present and that follow-up tests may be required. <br /> I understand that the results of these tests will be kept confidential and will only be released to <br /> medical personnel directly responsible for his or her medical benefit only, and to others as <br /> required by law. <br /> Consent or refusal and signature: <br /> I hereby consent to: <br /> HIV testing HBV testing HCV testing <br /> I hereby refuse consent to: <br /> HIV testing HBV testing HCV testing <br /> Source individuals identification: <br /> Printed name: <br /> Signature: Date: <br /> Relationship if signed by other than source individual: <br />