The undersigned hereby gives permission and consent to the University of Wisconsin-Milwaukee to perform a screening or confirmatory test for the human immunodeficiency virus (HIV) as considered necessary or essential for my protection or the protection of patients and employees of the University of Wisconsin-Milwaukee, where I am an employee.

I understand that the results of the screening or confirmatory tests will be held in the strictest confidence by the University and will be reviewed only with me, unless I give additional consent for disclosure of the results of such tests.

I further understand that the results of these tests may not be disclosed and that the University may not be compelled to disclose such information or test results involving communicable diseases, except as may be provided under state and federal law.

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Employee's Name (Please Print)

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Employee Signature

This consent and authorization given this_______day of _______________, 20______.

The undersigned refuses to give consent or submit any screening or confirmatory tests for any of the communicable diseases set forth and enumerated at the University of Wisconsin-Milwaukee.

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Employee's Name (please print)

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Employee Signature

Dated:_____________________________