HIPAA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT OF RECEIPT I have received a copy of Oxford Immunotec, Inc. Notice of Privacy Practices. (Signature of patient) (Date) (Print Name) For Oxford Immunotec, Inc. use only A written signature of this form was attempted but could not be obtained because: The individual refused to sign An emergency or or situation prevented obtaining this acknowledgment Or: 24914379v.1
CONSENT FOR TEST This consent form documents my consent to T-SPOT. test for active and latent (or inactive) tuberculosis () infection. I understand that this test is being requested as part of a screening event conducted on behalf of CUTOMER NAME ( Institution ). RISK SUMMARY The T-SPOT. test is a blood test requiring a sample of approximately 6mL of blood drawn by needle from my arm. I understand that re is a slight risk of bruising and mild discomfort associated with a blood draw. Anor risk of a blood draw is infrequent occurrence of fainting. The testing presents a risk to my privacy because results will be shared with Institution. I understand that I may withdraw my consent at any time; however, I may be requested to undergo alternative testing. My signature below indicates that I have read and understand this consent form, have had an opportunity to ask questions and that all of my questions have been answered. CONSENT Signature: Print Name: Date: T-SPOT is a registered trademark of Oxford Immunotec Ltd.
1 Student Health Center THE UNIVERSITY OF TEXAS AT DALLAS 800 W. Campbell Road SSB 43 Richardson, Texas 75080 (TEL) 972-883-2747 (FAX) 972-883-2069 Name (Please Print): Date of Birth: MM //DD/ YYYY U.S. Address: U.S. Phone #: U.S. Phone #: Email Address: Student ID#: Part I: Tuberculosis () Screening Questionnaire (to be completed by incoming students) Please answer following questions: Have ever had close contact with persons known or suspected to have active disease? Were born in one of countries or territories listed below that have a high incidence of active disease? (If yes, please CIRCLE country, below) Afghanistan Algeria Angola Anguilla Argentina Armenia Azerbaijan Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Central African Republic Chad China China, Hong Kong SAR China, Macao SAR Colombia Comoros Congo Côte d'ivoire Democratic People's Republic of Korea Democratic Republic of Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Ethiopia Fiji Gabon Gambia Georgia Ghana Greenland Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iraq Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lesotho Liberia Libya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal New Caledonia Nicaragua Niger Nigeria Norrn Mariana Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Sao Tome and Principe Senegal Serbia Sierra Leone Singapore Solomon Islands Somalia South Africa South Sudan Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Tanzania (United Republic of) Thailand Timor-Leste Togo Tunisia Turkmenistan Tuvalu Uganda Ukraine Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2015. Countries with incidence rates of 20 cases per 100,000 population. For future updates, refer to http://www.who.int/tb/country/en/. Have had frequent or prolonged visits* to one or more of countries or territories listed above with a high prevalence of disease? (If yes, CHECK countries or territories, above) Have been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and homeless shelters)? Have been a volunteer or health care worker who served clients who are at increased risk for active disease?
Have ever been a member of any of following groups that may have an increased incidence of latent M. tuberculosis infection or active disease: medically underserved, low-income, or abusing drugs or alcohol? 2 Have ever had a positive skin test or IGRA blood test? Have ever received BCG (bacille Calmette-Guerin) vaccination? Have had an MMR or Chicken Pox vaccine in past 6 weeks? **Do have any allergies to latex or rubber products? _ Symptom Check In last year have had any of following: Cough (especially if lasting for 3 weeks or longer) with or without sputum production Coughing up blood (hemoptysis) Chest pain Loss of appetite Unexplained weight loss Night sweats Fever Please read carefully Please read carefully The T-Spot test is a blood test for tuberculosis () screening, an alternative to skin test. This test is performed using blood The collection T-Spot and test is not is a affected blood test by for previous tuberculosis BCG () vaccination. screening, an Also, alternative re are to no adverse skin test. effects This for women test is performed who are using pregnant blood since it is a blood collection draw and and not is an not injection. affected by Your previous test BCG results vaccinations. will be Also, available re within are no adverse 4 business effects days for after women who blood are draw. pregnant The since it hold is a will be removed blood from draw r and student not an injection. account Your after reviewing test results will lab be results available and within determining 4 business days do not after have blood active draw.. The The hold blood will test be is removed from r student account after reviewing lab results and determining do not have active. The blood test is not not always conclusive and may require a follow-up chest x-ray at r own expense. The Student Health Center will contact if a always conclusive and may require a follow-up chest x-ray at r own expense. The Student Health Center will contact if a chest x- chest x-ray ray is is required. required. The cost The of cost of T-Spot T-Spot test test administered by by Student Health Center is is $75. $75. The Student Health Center will file insurance claims directly with Blue Cross Blue Shield on behalf of those students who are covered by plan. Students not covered by UT SHIP r student account will be charged $75 and should be paid along with or charges may owe University after registering for classes. Consent for Screening Consent for Screening By signing By signing below, below, are are giving giving r r consent consent for for Student Student Health Health Center Center to to administer administer T-Spot T-Spot test, acknowledging test, acknowledging that that have have read read and and understand understand information provided above, above, and and that that agree agree to pay to pay $75 charge $75 charge when at pay time r of student service. account. Nonpayment will result in a hold being applied to r student account. I have read and understand above information and consent to test. I have read and understand above information and consent to test. Signature: Date: Signature: Date: For Student Health Center Only T-spot Blood Test- Standing Order: S. Naheed, MD Date Collected: Time Collected: Phlebotomist/Nurse Signature: Revised 06/28/2017
3 June 2017 Prepared originally by ACHA s Tuberculosis Guidelines Task Force Revised by Emerging Public Health Threats and Emergency Response Coalition NOTE: Any student submitting false or fraudulent information will be subject to disciplinary action. The University of Texas at Dallas Is an Equal Opportunity/ Affirmative Action University