STUDENTS WITH HI V-RELATED ILLNESS EXHIBIT
The University of the State of New York Education Department
Authorization for Release of Confidential HIV*Related Information
to the Superintendent of Schools and the Board of Education
Approved by New York State Department of HealthOC-l (6/89)
Confidential HIV Related Information means any information indicating that a person had an HIV related test, or has HIV infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
Under New York State Law, except for certain people, confidential HIV related information can only be given to persons you allow to bave it by signing this form. You may ask for a list of people who can~be given confidential HIV related information even without this form.
If you sign this form. HIV related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you experience discrimination because of the release of HIV related information, you may contact the New York State Division of Human Rights at (212) 870-9624 or the New York City Cozhmission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.
NAME OF PERSON WHOSE HIV RELATED INFORMATION WILL BE RELEASED
NAME AND ADDRESS OF PERSON SIGNING THIS FORM (IF OTHER THAN ABOVE)
STREET
CITY STATE ZIP CODE
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| RELATIONSHIP TO PERSON WHOSE HIV INFORMATION WILL BE RELEASED
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| Name and addresses of the Superintendent of Schools and individual members of the Board of Education (Board of Trustees) of the above named school district who will be given HIV related information.
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| SUPERINTENDENT’S NAME
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STREET
CITY STATE ZIP CODE
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| NAME
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STREET
CITY STATE ZIP CODE
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NAME
5191 -E
| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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| NAME
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| STREET CITY
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STATE ZIP CODE
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Reason for release of HIV related information
~ To approve the recommendation of the
(Name of district)
~ Other (explain in full, use additional sheet(s) if necessary
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CSE as required by law.
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Mv questions about this form have been answered. I know that I do not have to allow release of HIV refated information. and that I can change my mind at any time.
Signature
Adoption date: May 21. 1997
Date
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