Form CT-14 "Human Immunodeficiency Virus (Hiv) Antibody Test Consent Form (Serology)" - New Jersey

What Is Form CT-14?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CT-14 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form CT-14 "Human Immunodeficiency Virus (Hiv) Antibody Test Consent Form (Serology)" - New Jersey

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HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIBODY TEST
CONSENT FORM (SEROLOGY)
This is not a test for AIDS. This is a test for antibodies to the virus named HIV. A counselor has told
me what a negative or positive test result means. On my return visit, a counselor will explain my test
results to me.
I understand that knowing my HIV result is important to my health. I understand that if I test
confidentially at this clinic, I will sign my name, address and phone number on this form. This is the
best way for me to enter into treatment and to learn of other available services. It is also a way for
someone to reach me if I cannot return for my test results.
An anonymous test means that I do not use my real name or address, but it also means that no one
will be able to reach me if I cannot return for my results. In addition, no one can reach me if I am in
need of other services.
However I choose to test, I will get a code number. This number will be on the consent form, lab slip
and specimen tube. The lab slip and specimen tube will be sent to the State laboratory where the
test will be done. My code number, not my name, will be on the lab slip and the specimen tube. All
records are kept under lock and key.
Should I test positive this information will be reported to the New Jersey Department of Health as
required by law. Any other release of this information will require my written consent or a court order
or subpoena. I have read or someone has read this form to me. All of my questions have been
answered. If I want to test confidentially, I will sign my name, address and phone number. If I want
to test anonymously, I will sign John/Jane Doe.
______________________________________
_____________________________________
(Signature of Witness)
(Signature of Client)
______________________________________
_____________________________________
(Code Number)
(Street Address)
______________________________________
_____________________________________
(Date)
(City and State)
_____________________________________
(Phone Number)
CT-14
JUL 12
HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIBODY TEST
CONSENT FORM (SEROLOGY)
This is not a test for AIDS. This is a test for antibodies to the virus named HIV. A counselor has told
me what a negative or positive test result means. On my return visit, a counselor will explain my test
results to me.
I understand that knowing my HIV result is important to my health. I understand that if I test
confidentially at this clinic, I will sign my name, address and phone number on this form. This is the
best way for me to enter into treatment and to learn of other available services. It is also a way for
someone to reach me if I cannot return for my test results.
An anonymous test means that I do not use my real name or address, but it also means that no one
will be able to reach me if I cannot return for my results. In addition, no one can reach me if I am in
need of other services.
However I choose to test, I will get a code number. This number will be on the consent form, lab slip
and specimen tube. The lab slip and specimen tube will be sent to the State laboratory where the
test will be done. My code number, not my name, will be on the lab slip and the specimen tube. All
records are kept under lock and key.
Should I test positive this information will be reported to the New Jersey Department of Health as
required by law. Any other release of this information will require my written consent or a court order
or subpoena. I have read or someone has read this form to me. All of my questions have been
answered. If I want to test confidentially, I will sign my name, address and phone number. If I want
to test anonymously, I will sign John/Jane Doe.
______________________________________
_____________________________________
(Signature of Witness)
(Signature of Client)
______________________________________
_____________________________________
(Code Number)
(Street Address)
______________________________________
_____________________________________
(Date)
(City and State)
_____________________________________
(Phone Number)
CT-14
JUL 12