Poudre Valley Hospital

Form C2.104 University of Colorado Cord Blood Bank HIV CONSENT Poudre Valley Hospital Implemented 7-19-05

I understand that my blood will be tested for the HIV virus. This is the virus that causes the acquired immune deficiency syndrome (AIDS). This test will NOT tell me if I have AIDS or any AIDS-related condition. It does show whether I have been infected with the virus that can cause AIDS.

I understand that the test’s accuracy and reliability are still uncertain. Occasionally the test results show that a person has antibodies to the virus when he or she does not. Occasionally the test fails to detect antibodies to the virus when the person has been exposed. I also understand that a positive blood test result does not mean that I have AIDS. In order to diagnose AIDS, other means must be used in addition to the blood test. I understand that if the test is positive, I am probably infected and could infect others. These include another sex partner, needle-sharing partner or, if pregnant, my unborn baby. If the test is negative and I have been involved in high risk behavior (sharing intravenous needles, or having sex without using a condom), I could still be infected but it may be too early to tell by blood test.

I understand that my medical record maintained by Poudre Valley Hospital will contain this consent form signed by my physician and me. It will also contain a copy of the test result. I also understand that the information contained in my medical record is available to any agency holding a current authorization for release of information signed by me. These include insurance companies, Medicare and Medicaid.

I understand that if my blood does contain antibodies to the HIV virus, resulting In a positive test result, that the physician who ordered the test will be informed. That physician must let me know my test result. That physician may also tell other health care providers who are directly responsible for my care and treatment so they may take proper precautions when providing care to me. I especially understand that in the case of a positive result, my name, address, sex and date of birth will be reported to the Colorado Department of Health as required by law.

I have read this consent form and understand the provisions for release of information as set forth in this consent.

I AM GIVING MY CONSENT TO BE TESTED FOR THE HIV ANTIBODY.

Patient/Guardian ______Date______

CB Collection Label Page 1 of 2

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Will the HIV test tell me if I have AIDS? No. A positive finding means you have been exposed to the virus and that you have become infected. While some people infected with the virus have gone on to develop AIDS, others have not. Changes in lifestyle, diet, behavior and early treatment may help you delay or avoid the development of AIDS. These tests will not tell you if you have AIDS, whether you will develop AIDS or how long you’ve been infected.

How does a person become infected with HIV? The virus is most commonly spread through sexual contact (vaginal, anal or oral sex). It also is commonly spread by sharing of dirty needles/works during illegal use of (shooting) intravenous drugs. An infected mother may infect her baby during pregnancy, at the time of birth, or while breast feeding. Very rarely, contact with blood in other ways may also spread the virus. You can NOT get infected with the virus by donating blood.

Are there any risks involved in having the test done? There are virtually no medical risks in drawing a small sample of blood. Only sterile needles and syringes are used for this purpose. Once the needle or syringe is used, it is safely thrown away. Before you are tested, you should carefully think about to whom you would tell the results and what emotional and support systems are available to you. If you are not sure, discuss this with your health professional now. While health professionals are required to keep this information confidential, others outside the health profession are concerned about HIV and AIDS. Some people may not understand the nature of the infection, and this misunderstanding may result in problems with family, friends, coworkers or others. As with any serious health problem, some people who have taken the test and who have discovered that they are now infected with HIV have experienced emotional problems. Your health professional is aware of support programs for people who test positive. You, however, should carefully consider what support you may require if you test positive.

What if I have more questions? Please ask the health professional who gave you this consent. Your health professional will have the answers to your questions or will be in a position to get the answers for you.

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D:\Docs\2017-11-30\02acd9d2e1ae4d50fe34d1faae452e36.doc Form C2.104 University of Colorado Cord Blood Bank HIV CONSENT Poudre Valley Hospital Implemented 7-19-05 DONOR EDUCATIONAL MATERIALS

MAKING YOUR CORD BLOOD DONATION SAFE

Thank you for agreeing to donate cord blood today! This information sheet explains how YOU can help us make the donation process safe for yourself and patients who might receive your blood. PLEASE READ THIS INFORMATION BEFORE YOU DONATE! If you have any questions now or anytime during the screening process, please ask the staff.

ACCURACY AND HONESTY ARE ESSENTIAL! Your complete honesty in answering all questions is very important for the safety of patients who receive your blood. All information you provide is confidential.

DONATION PROCESS: To determine if you are eligible to donate we will: -Ask questions about health, travel, and medicines -Ask questions to see if you might be at risk for hepatitis, HIV, or AIDs - Ask questions about your family history If you are able to donate we will: - Cleanse your umbilical cord with an antiseptic. -Use a new, sterile, disposable needle to collect your cord blood

DONOR ELIGIBILITY – SPECIFIC INFORMATION

Why we ask questions about sexual contact: Sexual contact may cause contagious diseases like HIV to get into the bloodstream and be spread through transfusions to someone else. Definition of “sexual contact”: The words “have sexual contact with” and “sex” are used in some of the questions we will ask you, and apply to any of the activities below, whether or not a condom or other protection was used: 1. Vaginal sex (contact between penis and vagina) 2. Oral sex (mouth or tongue on someone’s vagina, penis, or anus) 3. Anal sex (contact between penis and anus)

HIV/AIDS RISK BEHAVIORS AND SYMPTOMS AIDS is caused by HIV. HIV is spread mainly through sexual contact with an infected person OR by sharing needles or syringes used for injecting drugs.

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DONOR EDUCATIONAL MATERIALS

DO NOT DONATE IF YOU: -Have AIDS or have ever had a positive HIV test -Have ever used needles to take drugs, steroids, or anything not prescribed by your doctor - Had sex with a male who has had sexual contact with another male, even once, since 1977 - Have ever taken money, drugs or other payment for sex since 1977 - Have had sexual contact in the past 12 months with anyone described above - Have had syphilis or gonorrhea in the past 12 months - In the last 12 months have been in juvenile detention, lockup, jail or prison for more than 72 hours -Have any of the following conditions that can be signs or symptoms of HIV/AIDS: Unexplained weight loss or night sweats Blue or purple spots in your mouth or skin Swollen lymph nodes for more than one month White spots or unusual sores in your mouth Cough that won’t go away or shortness of breath Diarrhea that won’t go away Fever of more than 100.5 oF for more than 10 days Remember that you CAN give HIV to someone else through blood even if you feel well and have a negative HIV test. This is because tests cannot detect infections for a period of time after a person is exposed to HIV. If you think you may be at risk for HIV/AIDS or want an HIV/AIDS test, please ask for information about other testing facilities. PLEASE DO NOT DONATE TO GET AN HIV TEST!

Travel to or birth in other countries Blood donor tests may not be available for some contagious diseases that are found only in certain countries. If you were born in, have lived in, or visited certain countries, you may not be eligible to donate.

What happens after your donation: To protect patients, your blood is tested for hepatitis B and C, HIV, certain other viruses, and syphilis. If your blood tests positive it will not be given to a patient. You will be notified about test results that may disqualify you from donating in the future. Please do not donate to get tested for HIV, hepatitis, or any other infections!

Thank you for donating your cord blood today!

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University of Colorado Cord Blood Bank (303) 724-1306 DONOR EDUCATIONAL MATERIALS

What is an HIV Test? Human Immunodeficiency Virus (HIV) is the virus that causes Acquired Immune Deficiency Syndrome (AIDS). Laboratory tests tell whether you have been infected with HIV. A test is not considered positive unless a different backup test is done and also reads positive. Test results that are inconclusive should be discussed with your health professional.These tests are conducted on a single sample of your blood. Will the HIV test tell me if I have AIDS? No. A positive finding means you have been exposed to the virus and that you have become infected. While some people infected with the virus have gone on to develop AIDS, others have not. Changes in lifestyle, diet, behavior and early treatment may help you delay or avoid the development of AIDS. These tests will not tell you if you have AIDS, whether you will develop AIDS or how long you’ve been infected. How does a person become infected with HIV? The virus is most commonly spread through sexual contact (vaginal, anal or oral sex). It also is commonly spread by sharing of dirty needles/works during illegal use of (shooting) intravenous drugs. An infected mother may infect her baby during pregnancy, at the time of birth, or while breast feeding. Very rarely, contact with blood in other ways may also spread the virus. You can NOT get infected with the virus by donating blood. Are there any risks involved in having the test done? There are virtually no medical risks in drawing a small sample of blood. Only sterile needles and syringes are used for this purpose. Once the needle or syringe is used, it is safely thrown away. Before you are tested, you should carefully think about to whom you would tell the results and what emotional and support systems are available to you. If you are not sure, discuss this with your health professional now. While health professionals are required to keep this information confidential, others outside the health profession are concerned about HIV and AIDS. Some people may not understand the nature of the infection, and this misunderstanding may result in problems with family, friends, coworkers or others. As with any serious health problem, some people who have taken the test and who have discovered that they are now infected with HIV have experienced emotional problems. Your health professional is aware of support programs for people who test positive. You, however, should carefully consider what support you may require if you test positive. What if I have more questions?

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Please ask the health professional who gave you this consent. Your health professional will have the answers to your questions or will be in a position to get the answers for you.

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