The HIV test or “AIDS” test is a blood test which when reported as positive indicates that the person

tested
has developed antibodies to the virus that causes AIDS. A positive test result is not/ not a diagnosis of
AIDS. It indicates that a person has been infected and is assumed to be capable of transmitting the virus,
regardless of whether he or she shows symptoms. Testing for HIV is only effective way for a person to
determine whether she/he become infected with the virus. HIV exposure and transmission can be
avoided or minimized by specific actions. A negative HIV Test means that antibodies to the virus are not
detectable at the time of testing. However, there can be an interval of time following infections and
before the appearance of HIV antibodies-known as the serologic “window period”-usually no longer than
6 months in 99% of individuals eventually testing positive. A negative HIV test result provides an
opportunity to change behavior in order to avoid or reduce future HIV exposure.

My question about HIV test been answered. I agree to take the HIV antibody test.

Date : __________________________________________________________

Name : __________________________________________________________

Signature :__________________________________________________________

I have explained the HIV antibody test, the meaning of the results and possible related consequences of
both a negative and positive result.

Name of person providing counselling : ___________________________________________________

 INFORMED CONSENT FOR HIV TESTING A
The Department of Health (DOH) has an existing program for the prevention and control of the Human Immunodeficiency Virus (HIV) in
the Philippines. The National Epidemiology Center (NEC) of DOH is mandated by Republic Act 8504 to collect information which can
help in planning activities which will help halt the spread of HIV and be beneficial to the people. Your full cooperation is very important
to undertake this activity. We encourage you to answer all questions as honestly as possible.

ABOUT THE TEST

1. What is HIV testing?

An HIV test is a blood test. It will show if you have antibodies to HIV-- the virus that causes AIDS. A sample of blood will be taken from your arm. If
the first test (screening) is reactive, another test (confirmatory) will be done to make sure that the first test is confirmed to be positive. A positive test
means you have been infected with HIV, a negative test means you are probably not infected because it takes time for the body to produce
antibodies. If you think you have been exposed recently, you need to be re-tested after 3 - 6 months to make sure you are not infected.

2. Voluntary HIV testing

Taking an HIV test is voluntary. Under Republic Act 8504, you cannot be tested without your knowledge and consent. If you do not want to be
tested, you have the right to refuse the test.

3. Confidentially of Test Results

Your test result is confidential. It will only be given to you personally.

I was given information about HIV and HIV testing, Name:

and was given the opportunity to ask questions
during pretest counseling or group test information
I agree to be tested for HIV. Signature: Date:

PERSONAL INFORMATION SHEET (FORM A)

All information given will be STRICTLY CONFIDENTIAL. Please fill out this form COMPLETELY and as honestly as possible. Please
write in CAPITAL LETTERS and CHECK the appropriate boxes.
DEMOGRAPHIC DATA
1 PhilHealth Number: - - Not enrolled in PhilHealth
Name (Full name)
2
First Name Middle Name Last Name
Mother's Maiden Name (Full real name)
3
First Name Middle Name Last Name
UNIQUE IDENTIFIER CODE
First 2 letters of mother's real First 2 letters of Birth order Month of Birth Day of Birth Year of Birth
name father's real name
4

5 Age: Age in months (for less than 1 year old): Sex (at birth): Male Female

Permanent Address:
6 Current Place of Residence: Municipality/City: Province:
Place of Birth: Municipality/City: Province:

7 Contact Numbers: Email:

8 Nationality: Filipino Others, please specify:

Highest Educational Attainment: None Highschool Vocational

9
Elementary College Post-Graduate

10 Civil Status: Single Married Separated Widowed

11 Are you currently living with a partner? No Yes

12 Number of children: Are you presently pregnant? (for females only) No Yes
EMPLOYMENT
Current Occupation (Please specify main source of income):
13
If no current work, what was previous occupation:
Did you work overseas/abroad in the past 5 years? No Yes

If yes, when did you return from your last contract?

14 Month Year
Where were you based? On a ship Land
What country did you last work in?

PERSONAL INFORMATION SHEET (DOH-NEC FORM A 2014)

 REASON FOR HIV TEST
Reason for HIV Testing: (check all that apply)
Mother is infected with HIV Received blood transfusion TB patient
Sex partner is infected with HIV Wants to know HIV status Active Hepatitis B/C
15 Shared needles/syringes with IDUs Re-check previous HIV test result No particular reason
Accidental needle prick Employment - Local/In the Philippines Other (pls specify):
Recommended by physician Employment - Overseas/Abroad
Requirement for insurance Pregnant
HISTORY OF EXPOSURE
16 Was your birth MOTHER infected with HIV when you were born? No Yes

Answer all . Have you experienced any of the following? (If yes, state the MOST RECENT year)
Received blood transfusion No Yes If yes, what year:
Injected drugs without doctor's advice No Yes If yes, what year:
Accidental needle prick No Yes If yes, what year:
17 Sexually transmitted infections (STI) No Yes If yes, what year:
Sex with a female with no condom No Yes If yes, what year:
Sex with a male with no condom No Yes If yes, what year:
Sex with a person in prostitution No Yes If yes, what year:
Regularly accept payment for sex No Yes If yes, what year:
SEXUAL PARTNERS
Answer both. If none, write "0" in the box.

18 How many FEMALE sex partners have you ever had? Year of last sex with a female:

How many MALE sex partners have you ever had? Year of last sex with a male:
HIV TESTING

Have you ever been tested for HIV before? No Yes

If yes, when was the most recent test?

19 Month Year

Which testing facility did you have the test? Municipality/City:

What was the result? Positive Negative

To be filled up by PHYSICIAN, CLINIC STAFF or COUNSELOR only

Clinical Picture: Asymptomatic
20 Symptomatic Describe S/Sx:
World Health Organization (WHO) Staging: No physician available to do staging
To be filled up by TESTING FACILITY only

Name of Testing Facility:

HIV EQAS Lab Code: Year last participated in HIV EQAS:

21
Complete Mailing Address:

Contact Numbers: Email address:

Name of Medical Technologist:

22 HIV Proficiency Number:

Date Issued: Expiration Date:

Month Day Year Month Day Year

23 Name of Counselor (with signature):

To be filled up by SACCL only

SACCL Laboratory Code: Date HIV Confirmed:

24 Month Day Year

HIV Results Confirmed by: Test: Western Blot PCR for infants
END
PERSONAL INFORMATION SHEET (DOH-NEC FORM A 2014)
 CONFIDENTIAL
NATIONWIDE HEALTH SYSTEMS AUX. INC.
COVID-19 DAILY HEALTH CHECK QUESTIONNAIRE

To be filled out by the VISA APPLICANT (Please write clearly in BLOCK LETTERS.)
Instructions:
1. All clients, applicants, and patients shall accomplish this Form and must present the same to the Screening Officer upon entering the premises.
2. The screening shall consist of a temperature check and an assessment of the Covid-19 Daily Health Check Questionnaire.
3. A client, applicant, or patient who has a temperature of below 37.5 degrees Celsius and whose Questionnaire requires no further evaluation
shall be allowed to enter the premises.The Questionnaire shall be collected.
4. A client, applicant, or patient who has a temperature of 37.5. degrees Celsius and above and/or whose Questionnaire requires further evaluation
shall not be allowed entry, and shall be advised to seek further tests or endorsed to a Covid facility. The Questionnaire shall be collected.
5. Properly segregated collected Questionnaires (i.e. not allowed and allowed to enter) shall be collated and turned over to the NHS Aux Assistant
Medical Director at the end of every work day.

Name: (Last Name, First Name, Middle Name) Date: Temperature:

Mobile No.: E-mail address:

Complete Current Residential Address:

Yes No
1. Are you experiencing: a. Sore throat
(nakakaranas ka ba (pananakit ng lalamunan / masakit lumunok)  
ng:)
b. Body pains
(pananakit ng katawan)  
c. Headache
(pananakit ng ulo)
 
d. Fever for the past few days
(Lagnat sa nakalipas na mga araw)  

2. Have you worked together or stayed in the same close environment of a

confirmed COVID-19 case? (May nakasama ka ba o nakatrabahong tao  
na kumpirmadong may COVID-19 / may impeksyon ng coronavirus?)

3. Have you had any contact with anyone with fever, cough, colds, and sore
throat in the past 2 weeks? (Mayroon ka bang nakasama na may lagnat,  
ubo, sipon o sakit ng lalamunan sa nakalipas ng dalawang (2) lingo?)

4. Have you travelled outside of the Philippines in the last 14 days?

(Ikaw ba ay nagbyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)  

5. Have you travelled to any area in NCR aside from your home?  
(Ikaw ba ay nagpunta sa iba pang parte ng NCR o Metro Manila bukod sa iyong
bahay?) Specify(Sabihin kung saan):

This is to certify that the above information provided are true and correct to the best of my knowledge. I also authorize
NHS Aux / NHS Inc to collect and process the data indicated hereto for purpose of effecting control of the COVID -19
infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am
required by RA 11332 Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act to
provide truthful information.

Signature of Visa Applicant : ________________________________