Sample Hepatitis C Screening and Consent Form.
The Caring Ambassadors Program is providing this information to help you host a successful hepatitis C screening event.
We welcome your comments and suggestions.
Sample Hepatitis C Screening
Caring Ambassadors Program, Hepatitis C Division Should You Be Tested For Hepatitis C?
What is Hepatitis C?
Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). The hepatitis C virus can slowly cause liver damage over many years without causing any symptoms. The liver can eventually be damaged to the point that it can no longer perform its many jobs. There is no vaccine to prevent hepatitis C, but medical treatments are available to help prevent severe liver damage.
How Do You Get Hepatitis C?
Since people with hepatitis C generally do not feel sick, people can have the virus and unknowingly spread it to others. The hepatitis C virus is spread by blood-to-blood contact. The following series of questions will help you determine if you may have been exposed to the hepatitis C virus. People who may have been exposed to HCV should be tested.
Could You Have Been Exposed to the Hepatitis C Virus?
Check the box next to each statement that applies to you. Your responses are confidential.
Contact Information: Please PRINT Clearly
First Name: _________________
SAMPLE INFORMED CONSENT LANGUAGE:
The hepatitis C antibody test is a screening test to find out if you have ever been exposed to the hepatitis C virus. It cannot determine whether you still have the hepatitis C virus in your system. If your test result is indeterminate or positive, you must have additional testing to see if the hepatitis C virus is still in your system. This testing can be performed by your doctor. A [YOUR ORGANIZATION HERE] counselor will call you to let you know what you should do next if your test result is indeterminate or positive.
I authorize the [YOUR ORGANIZATION HERE] to collect blood for hepatitis C antibody testing, and to give me my test results by mail if negative, or by telephone if the results are positive or indeterminate.
Client Signature: _______________________________Date: ___/___/___
Counselor Signature: _____________________________________________