The University of the State of New York Education Department
Approved by: New York State Department of Health
Confidential HIV Related Information means any information indicating that a person had an HIV related test, or has HIV infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
Under New York State Law, except for certain people, confidential HIV related information can only be given to persons you allow to have it by signing this form. You may ask for a list of people who can be given confidential HIV related information even without this form.
If you sign this form, HIV related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you experience discrimination because of the release of HIV related information, you may contact the New York State Division of Human Rights at (212) 870-9624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.
*Human Immunodeficiency Virus that causes AIDS
NAME OF PERSON WHOSE HIV RELATED INFORMATION WILL BE RELEASED:
__________________________________________________________________
NAME AND ADDRESS OF PERSON SIGNING THIS FORM (IF OTHER THAN ABOVE):
Name: __________________________________________________________________
Address: _________________________________________________________________
RELATIONSHIP TO PERSON WHOSE HIV INFORMATION WILL BE RELEASED: _________________________
NAME OF SCHOOL DISTRICT: ____________________________________________________________
Names and addresses of the Superintendent of Schools and individual members of the Board of Education (Board of Trustees) of the above named school district who will be given HIV related information:
SUPERINTENDENT’S NAME: _____________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
NAME: __________________________________________________________________
Address: _________________________________________________________________
Reason for release of HIV related information (check one):
_____ To approve the recommendation of the _________________ CSE as required by law.
_____ Other (explain in full, use additional sheet(s) if necessary):
Time during which release is authorized FROM (Month Day Year): _________________ TO (Month Day Year): _________________
My questions about this form have been answered. I know that I do not have to allow release of HIV related information, and that I can change my mind at any time.
__________________________________________________________________
Signature
__________________________________________________________________
Date
January 25, 1999