Form 1424 Medical Screening for Blood-Borne Pathogens/Consent for

NATIONAL SCIENCE FOUNDATION
4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230

OFFICE OF POLAR PROGRAMS

Medical Screening for Blood-borne Pathogens
United States Antarctic Program (USAP) medical clinics at the three U.S. research stations do not maintain
supplies of frozen blood. NSF research stations in the Arctic do not have readily available blood supplies. In
the event of the need for a transfusion, other individuals at the research station with matching blood types
would be asked to donate fresh whole blood for the patient. In order to maintain a viable donor pool, the
National Science Foundation requests that USAP and Arctic participants during the austral summer season
voluntarily submit to testing for Human Immunodeficiency Virus (HIV) along with the required Hepatitis virus
B and C as part of their medical screening process. Please note that HIV testing is required for candidates
intending to spend the winter in Antarctica or in the Arctic.
Consent for HIV Antibody Blood Test
I have been informed that my blood will be tested for Human Immunodeficiency Virus (HIV) antibodies, the
causative agent of Acquired Immune Deficiency Syndrome (AIDS). I understand that the testing involves the
withdrawal of a small amount of my blood by venipuncture and subsequent testing of that blood sample via
ELISA and Western Blot methods.
I understand that if I have any questions regarding the testing procedure or interpretation of results, I should
discuss them with my health care provider. I understand that my examining physician will receive a copy of
these test results and may be required, under State law, to report positive test results to State Health Department
authorities and I consent to these disclosures.
I understand that the results of this blood test will be incorporated into my USAP medical file. All information
in that file is maintained in accordance with the Privacy Act (5 USC 552a) and protected against unauthorized
release, as described in the appended Privacy Notice.
Having read and understood the above statements, I hereby give my consent to the collection and testing of my
blood to determine the presence of HIV antibodies.

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Print Name

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Signature and Date

NSF Form 1424 Page 1 of 1 (APR 2002)
Original plus one copy: Contractor Medical Staff
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

Applicant: Please retain one copy for your records