Hepatitis C Challenge: Hep C Caring Ambassadors Program
HepC Choices

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.

The information is based on our experience hosting outdoor screening events. However, each event is different and you will need to customize your procedures according to the venue, length of the event, target audience, and other factors.

We welcome your comments and suggestions.


Sample Hepatitis C Screening
and Consent Form


Following is the screening and consent form used by CAP-Hepatitis C. If you are interested in using this form, please contact us.

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.

  • I had a blood transfusion before 1992.
  • I received blood products (immunoglobulin, anti-Rh factor, plasma, or platelets) before 1992.
  • I am a hemophiliac.
  • I have been on kidney dialysis.
  • My mother has hepatitis C.
  • Someone I live with now or have lived with in the past has hepatitis C.
  • I have injected or snorted street drugs (even once, even if it was many years ago).
  • I am a military combat veteran.
  • I have or have had a job that exposed me to blood (examples include health care workers, police officers, fire fighters, paramedics, and EMTs).
  • I have been incarcerated.
  • I participate or used to participate in a recreational activity (contact sports) that may have exposed me to blood.
  • I have shared personal hygiene equipment such as a razor, toothbrush, hair clippers, cuticle scissors, or nail clippers with others.
  • I have a tattoo that is more than 5 years old, or that was done in someplace other than a professional tattoo parlor.
  • I have had a body piercing (includes ears) that was not done by a professional.
  • I share body piercing jewelry with others.
  • I have had multiple sexual partners (10 or more sexual partners in my lifetime or more than 1 sexual partner in the last 6 months).
  • I have been exposed to blood during sexual activity.
  • I have had injections, surgery, or dental work done outside the U.S.
  • I have had abnormal liver blood tests.
  • None of the above applies to me, but I would still like to be screened for hepatitis C.

Contact Information: Please PRINT Clearly


First Name: _________________
Last Name: ___________________________
Date of Birth: ___/___/___ Sex: male female
Race: Caucasian African-American Hispanic
Asian/Pacific Islander Other
Mailing Address: ______________________________________________
Apartment Number: _________
City: __________________________________________ State: _____ Zip Code:___________
Telephone Number: (__ __ __) __ __ __ - __ __ __ __
OK to leave message? yes no


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.

Informed Consent

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: _____________________________________________


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Hepatitis C can show no symptoms until advanced liver damage develops.

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