Donor Information and Consent Form Leaflet

Donor Information and Consent Form
Leaflet

Author: Sharon Brown
Date: July 2019
Review date: July 2021
OHLF20.01

Introduction

It can be very frightening for Doctors and Nurses when blood or other body fluids
contaminate them at work. Very rarely blood contains viruses, which can be
contagious if they come into contact with damaged skin. As health care workers may
work for many years in close contact with their patients the risk of being
contaminated with blood is ever present. The fear of catching a blood borne virus is
therefore real.

The help we need

When a member of staff is contaminated with blood they themselves may require
treatment. In deciding which treatment is best we need your help in checking your
blood for 3 important viruses; Hepatitis B (HbsAg), hepatitis C and HIV. You have not
been singled out, as it is the hospital policy to approach all patients in this situation.

The chances of any of these viruses being present in your blood are extremely small.
However, should this be the case you will be told by the doctor and all the necessary
arrangement for future care will be made.

Please feel free to ask any further questions to the person who is obtaining your
consent today. This consent is entirely voluntary but if given will help us to reassure
and treat the member of staff involved in this incident.

People often worry that if they have a HIV test that it will affect them later on in life.
A negative HIV test taken purely because someone has been exposed to your blood
should not have an impact on a future request for insurance.

Consent

I __________________________________________________
___________________________________________________
Address ____________________________________________
___________________________________________________
___________________________________________________
I have read the leaflet “Donor Information” and consent to a blood sample being
taken and being tested for Hepatitis B (HbsAg) and hepatitis C and HIV.
I understand that this request is being made only as part of the management of an
incident of an individual who has been accidentally exposed to my blood or any other
body fluid.

Signature _____________________________________

Print Name ____________________________________

Date _________________________________________

Contact Us
Employee Wellbeing Services

Health & Wellness Centre
31-43 Ashfield Street

Royal London Hospital,
London, E1 2AH

Tel: 020 3594 6609
Fax: 020 7377 7621
www.bartshealth.nhs.uk