WRHA COMMUNITY SERVICES / PERSONAL CARE HOME
WRHA COMMUNITY SERVICES / PERSONAL CARE HOME
Post Exposure Prophylaxis Testing and Risk Factor Assessment
Consent Form for Source Person
I understand a Health Care Worker may have come in contact with my blood / body fluid:
I consent to:
• Have HIV and Hepatitis blood tests performed on me ( Yes ( No
• Provide information regarding my risk of having HIV or Hepatitis infection ( Yes ( No
I understand that for the HIV test, my blood will be labelled with a code and without my name so the results will be kept confidential.
I understand the exposed health care worker and their health care provider will be advised of my results and risk factors. This information is, otherwise, kept confidential.
I am aware that my result(s) will become a part of my Home Care / Personal Care Home health care record and the Occupational Health record of the exposed person.
If the results of my testing are significant, I would like my family doctor to be notified ( Yes ( No
My Family Doctor’s name is: ________________________________
Name of Clinic ___________________________________________
_____________________________ ______________________________________
Name of Source Person (Print) Signature of Source Person / Legal Guardian
❑ Check here if verbal consent is given instead of written consent
_____________________________ ___________________________
Name of Witness (Print) Signature of Witness
___________________________
Date
Information for Person Seeking Consent
Source patients should be counselled that this form is necessary for the Physician or Occupational Health Nurse to determine what action is needed to prevent the spread of HIV or Hepatitis to the exposed person. The source person should be advised that the information sought is very personal and that it will be necessary to share it with the exposed person and the health care provider. The source patient should be re-assured that the information will be kept confidential from everyone else.
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