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Source Individual's Consent or Refusal <br /> for HIV, HBV, and HCV Infectivity <br /> Source Individual is the person whose blood or body fluids provided the source of this <br /> exposure. <br /> Exposed Individual's Information <br /> Name (Please Print): <br /> Address: <br /> Phone Number: <br /> Exposure Date: <br /> Mo/Day/Yr <br /> Source Individual's Statement of Understanding: <br /> I understand that employers are required by law to z ttempt to obtain consent for HIV, HBV, <br /> and HCV infectivity testing each time an employee is exposed to the blood or bodily fluids of <br /> any individual. I understand that a body art practitioner has been accidentally exposed to <br /> my blood and that testing for HIV, HBV, and HCV infectivity is requested. I am not required <br /> to give my consent, but if I do, my blood will be tested for these viruses at no expense to <br /> 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 <br /> not 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 <br /> to medical personnel directly responsible for my care and treatment, to the exposed body <br /> art practitioner for his or her medical benefit only, and to others only as required by law. <br /> Consent or Refusal & Signature <br /> I hereby consent to.- <br /> M <br /> HIV Testing HBV Testing HCV Testing <br /> I hereby refuse consent to: <br /> HIV Testing HBV Testing HCV Testing <br /> Source Individual Identification <br /> Source Individual's Printed Name: <br /> Source Individual's Signature- Date: <br /> Relationship if signed by other than the Source Individual: <br /> W 0SWEH-PROGRAMS&PROJECTS\BODY ART\FORMS\WORD DOC&INFECTION PREVENTION AND CONTROL PLAN 5 31 12.doc <br /> 0 <br /> Page 17 of 17 <br /> M <br />