Cjukfcbt yf dsgjkytybt 'rcghtcc-----ntcnf yf DBX d hjlbkmyjv jnltktybb> jcyjdfyyjtLtgfhnfvtyn plhfdjj[hfytybz infnf Ym/-Qjhr

Bycnbnen ghj,ktv CGBLf yf gjkextyyjq byajhvfwbb !Gj;fkeqcnf> j,hfnbnt dybvfybt> xnj lkz gjkextybz cjukfcbz yf 'rcghtcc-----ntcn vj;tn ,snm bcgjkmpjdfyf kb,j lfyyfz ajhvf>

kb,j cnfylfhnyfz ajhvf cjukfcbz yf ntcn yf DBX@

Ghj[j;ltybt ntcnf yf DBX zdkztncz lj,hjdjkmysv b nht,etn gbcmvtyyjuj cjukfcbz gfwbtynf. Wtkm 'rcghtcc-ntcnf yf DBX – jghtltkbnm> byabwbhjdfys kb ds DBX – dbhecjv> rjnjhsq dspsdftn CGBL. Tckb ds DBX-byabwbhjdfys> nj dj dhtvz hjljd ,kfujlfhz 'rcghtcc-ntcne yf DBX dfv ytvtlktyyj ,elen lfys ytj,[jlbvst ktrfhcndtyyst ghtgfhfns lkz evtymitybz hbcrf gthtlfxb DBX yjdjhj;ltyyjve> f ht,tyre fyfkjubxyst ktrfhcndtyyst ghtgfhfns ,elen lfys chfpe gjckt hj;ltybz. Ght;lt xtv lfnm cjukfcbt yf dsgjkytybt ntcnf yf DBX> gjujdjhbnt c dhfxjv j cktle/otv%

j njv> rfr gthtlftncz DBX jn xtkjdtrf r xtkjdtre b jn vfnthb r ht,tyre& j ktrfhcndtyys[ ghtgfhfnf[> ljcnfnjxyj 'aatrnbdyj ghtljndhfof/ob[ gthtlfxe DBX jn vfnthb r ht,tyre dj vyjub[ ckexfz[& j pfrjyt infnf Ym/-Qjhr> cjukfcyj rjnjhjve dct yjdjhj;ltyyst ljk;ys ghjqnb ntcn yf DBX gjckt hj;ltybz !cjukfcbt hjlbntktq yt nht,etncz@& f nfr;t j pyfxtybb ghtldfhbntkmys[ htpekmnfnjd ntcnjd yf DBX b j njv> rfr gjlndth;lftncz gjkj;bntkmysq htpekmnfn ntcnf yf DBX.

Tckb ds cjukfcys c yb;tcktle/obv b [jnbnt lfnm cjukfcbt yf dsgjkytybt 'rcghtcc-ntcnf yf DBX> gj;fkeqcnf> gjcnfdmnt gjlgbcm b lfne yf j,hfnyjq cnjhjyt ajhvs.

Vtyz ghjrjycekmnbhjdfkb j gjkmpt ghj[j;ltybz 'rcghtcc-ntcnf yf DBX> b z gjybvf/> xnj DBX-byatrwbz vj;tn gthtlfdfnmcz jn vfnthb r ht,tyre.

Z gjybvf/> xnj% • Dbhec bvveyjltabwbnf xtkjdtrf !DBX@ – 'nj dbhec> rjnjhsq dspsdftn CGBL. • Jlby bp cgjcj,jd gthtlfxb DBX – 'nj gthtlfxf gjkjdsv gentv> gj'njve dct ,thtvtyyst ;tyobys gjldth;tys hbcre pfhf;tybz DBX. • DBX vj;tn gthtlfdfnmcz ht,tyre jn vfnthb ghb ,thtvtyyjcnb> hjlf[ b rjhvktybb uhelm/. • Tckb e vtyz DBX> nj 'nj cthmtpyjt pf,jktdfybt> rjnjhjt vj;tn jnhf;fnmcz yf vjtv pljhjdmt b pljhjdmt vjtuj ht,tyrf. • Htpekmnfns ntcnjd yf fynbntkf r DBX zdkz/ncz rjyabltywbfkmysvb> b pfrjy pfghtoftn lbcrhbvbyfwb/ gfwbtynjd d cdzpb c DBX.

Tckb ,eltn ecnfyjdktyj> xnj z DBX-byabwbhjdfyf> nj ceotcndetn ktxtybt> gjpdjkz/ott evtymibnm hbcr pfhf;tybz ht,tyrf% • Tckb hjls tot yt ghjbpjikb> vyt vjuen ,snm chjxyj yfpyfxtys ktrfhcndtyyst ghtgfhfns> pyfxbntkmyj cyb;f/obt hbcr gthtlfxb

dbhecf ht,tyre. • Ht,tyre vjuen ,snm yfpyfxtys ktrfhcndtyyst ghtgfhfns> evtymif/obt hbcr pfhf;tybz DBX. • Tckb ktrfhcndtyyst ghtgfhfns> gjpdjkz/obt evtymibnm hbcr gthtlfxb DBX> ,elen yfpyfxtys vyt dj dhtvz hjljd bkb yjdjhj;ltyyjve

chfpe gjckt hj;ltybz> nj dthjznyjcnm njuj> xnj ht,tyjr ,eltn DBX-byabwbhjdfy> pyfxbntkmyj cyb;ftncz. • Tckb ,eltn yfxfnj ktxtybt> dhfx hfccrf;tn vyt j k/,s[ gjcktlcndbz[ ghbtvf ktrfhcndtyys[ ghtgfhfnjd.

D infnt Ym/-Qjhr ceotcndetn ghjuhfvvf j,cktljdfybz yjdjhj;ltyys[% • Tckb z yt lfv cjukfcbt yf dsgjkytybt 'rcghtcc-ntcnf ctqxfc> ht,tyjr ,eltn ghjdthty yf DBX chfpe gjckt hj;ltybz. • Dct ltnb> hjlbdibtcz d infnt Ym/-Qjhr> ghj[jlzn gkfyjdst ntcns yf DBX d hfvrf[ ghjuhfvvs j,cktljdfybz yjdjhj;ltyys[>

b j htpekmnfnf[ ntcnjd cjj,oftncz vfnthzv.

Ntcn> yf rjnjhsq z lf/ cjukfcbt> gjpdjkbn vyt b vjtve dhfxe epyfnm htpekmnfn d ntxtybt 12 xfcjd% • D ckexft 'rcghtcc-ntcnf yf DBX vyt cjj,ofn htpekmnfn yt gjplytt xtv xthtp 12 xfcjd gjckt pf,jhf rhjdb. • D ckexft jnhbwfntkmyjuj htpekmnfnf 'rcghtcc-ntcnf yf DBX ybrfrb[ lheub[ ntcnjd yf lfyysq vjvtyn dsgjkyznmcz yt ,eltn. • Jnhbwfntkmysq htpekmnfn 'rcghtcc-ntcnf yf DBX gjxnb yfdthyzrf jpyfxftn> xnj z yt byabwbhjdfyf DBX> jlyfrj ntcn vj;tn yt dszdbnm

byatrwb/ d ckexft ytlfdytuj pfhf;tybz. • Ghtldfhbntkmysq gjkj;bntkmysq htpekmnfn ntcnf yf DBX jpyfxftn> xnj z> dthjznyj> DBX-byabwbhjdfyf b ht,tyjr ,sk gjldth;ty

rjynfrne c dbhecjv. Lkz gjlndth;ltybz ghtldfhbntkmyjuj gjkj;bntkmyjuj htpekmnfnf ,eltn dsgjkyty dnjhjq ntcn. • Z gjybvf/> xnj tckb ghtldfhbntkmysq htpekmnfn ntcnf jrf;tncz gjkj;bntkmysv> nj e vtyz> ytcvjnhz yf 'nj> vj;tn yt ,snm

DBX-byatrwbb !byjulf gjkj;bntkmyst htpekmnfns ntcnf ,sdf/n jib,jxysvb@> jlyfrj ,eltn kexit yfxfnm ktxtybt> xnj,s yt ljgecnbnm gthtlfxb byatrwbb ht,tyre dj dhtvz j;blfybz htpekmnfnf gjlndth;lf/otuj ntcnf.

• D ckexft ghtldfhbntkmyjuj gjkj;bntkmyjuj htpekmnfnf ntcnf yf DBX dhfx gjcjdtnetn vyt yt yfxbyfnm rjhvktybt uhelm/ lj gjkextybz htpekmnfnf gjlndth;lf/otuj ntcnf.

Dct ghtldfhbntkmyst gjkj;bntkmyst htpekmnfns ntcnjd ljk;ys ,snm gjlndth;ltys% • Tckb htpekmnfn gjlndth;lf/otuj ntcnf yf DBX ,eltn jnhbwfntkmysv> vyt b ht,tyre ytvtlktyyj ghtrhfnzn lfdfnm ktrfhcndtyyst

ghtgfhfns> rjnjhst ,skb yfpyfxtys lkz ghtljndhfotybz gthtlfxb DBX ht,tyre. • Tckb htpekmnfn gjlndth;lf/otuj ntcnf yf DBX jrf;tncz gjkj;bntkmysv> ghbtv ktrfhcndtyys[ ghtgfhfnjd> yfpyfxtyys[

lkz ghtljndhfotybz gthtlfxb DBX ht,tyre> ,eltn ghjljk;ty.

DOH-4158RUS (6/04) p1 of 2

• D ckexft gjkj;bntkmyjuj htpekmnfnf gjlndth;lf/otuj ntcnf gjnht,etncz dsgjkytybt ljgjkybntkmyjuj ntcnf> xnj,s jghtltkbnm> byabwbhjdfy ht,tyjr bkb ytn.

• D ckexft gjkj;bntkmyjuj htpekmnfnf gjlndth;lf/otuj ntcnf z ,ele yfghfdktyf r dhfxe lkz gjkextybz ljkujchjxyjq vtlbwbycrjq gjvjob> ytj,[jlbvjq vyt cfvjq> f nfr;t vtyz yfghfdzn r dhfxe> rjnjhsq gjpf,jnbncz j, eljdktndjhtybb vtlbwbycrb[ gjnht,yjcntq ht,tyrf.

Rjyabltywbfkmyjcnm byajhvfwbb> cdzpfyyjq c ghj[j;ltybtv ntcnjd yf DBX Htpekmnfns ntcnjd yf fynbntkf r DBX zdkz/ncz rjyabltywbfkmysvb. Cjukfcyj pfrjyfv infnf Ym/-Qjhr rjyabltywbfkmyfz byajhvfwbz vj;tn gthtlfdfnmcz njkmrj ntv kbwfv> d jnyjitybb rjnjhs[ ,skj gjkextyj gbcmvtyyjt hfphtitybt gfwbtynf> bkb kbwfv> rjnjhsv ytj,[jlbvj pyfnm j cnfnect gfwbtynf lkz jrfpfybz vtlbwbycrjq gjvjob b ghtljcnfdktybz eckeu> drk/xfz% cgtwbfkbcnjd> ghtljcnfdkz/ob[ vtlbwbycrbt eckeub& kbw> exfcnde/ob[ d j,tcgtxtybb e[jlf b ecsyjdktybb& hjlbntktq b jgtreyjd> cjukfcys[ yf e[jl pf ytcjdthityyjktnybvb& hf,jnybrjd n/htv ljkujchjxyjuj b rhfnrjchjxyjuj cjlth;fybz b cjnhelybrjd> hf,jnf/ob[ c jn,sdf/obvb ghj,fwb/ bkb eckjdyj jcdj,j;ltyysvb& hf,jnybrjd jnltktybq crjhjq b ytjnkj;yjq gjvjob b lheub[ cjnhelybrjd ,jkmybw> ghjxb[ ht;bvys[ exht;ltybq b vtlbwbycrb[ cke;,> rjnjhst rjynfrnbhe/n c rhjdm/#;blrjcnzvb jhufybpvf ghb dsgjkytybb bvb cke;t,ys[ j,zpfyyjcntq& jhufybpfwbb> rjnjhst cktlzn pf rfxtcndjv ghtljcnfdkztvs[ gfwbtynfv eckeu. Rhjvt njuj> pfrjy hfphtiftn gthtlfxe byajhvfwbb j DBX d ytrjnjhs[ jghtltktyys[ ckexfz[% gj cgtwbfkmyjve hfcgjhz;tyb/ celf& cke;fobv caths plhfdjj[hfytybz cjukfcyj pfrjye& cnhf[jdsv rjvgfybzv ghb ytj,[jlbvjcnb jgkfns vtlbwbycrb[ eckeu b ktxtybz.

Hfcrhsnbt lfyys[ j gfwbtynt Dfit bvz ,eltn cjj,otyj ltgfhnfvtyne plhfdjj[hfytybz d ckexft gjlndth;ltyyjuj gjkj;bntkmyjuj htpekmnfnf> gjkextyyjuj d [jlt rjyabltywbfkmyjuj ntcnf yf fynbntkf r DBX> yf jcyjdfybb htpekmnfnjd lheub[ ntcnjd> bvt/ob[ jnyjitybt r DBX> yf jcyjdfybb gjcnfyjdrb lbfuyjpf CGBL bkb d njv ckexft> tckb ds htibnt erfpfnm cdjt bvz d ckexft gjkj;bntkmyjuj htpekmnfnf ntcnf> ghjdjlbvjuj d fyjybvyjv geyrnt ghj[j;ltybz ntcnjd. Ltgfhnfvtyn plhfdjj[hfytybz ,eltn bcgjkmpjdfnm 'ne byajhvfwb/ d wtkz[ yf,k/ltybz pf 'gbltvbtq b kexituj gkfybhjdfybz ghjabkfrnbrb> vtlbwbycrjuj j,cke;bdfybz b ktxtybz.

Edtljvktybt gfhnythjd D ckexft gjkj;bntkmyjuj htpekmnfnf ntcnf yf DBX dhfx gjujdjhbn c dfvb j df;yjcnb b gjkmpt cjj,otybz gfhnythfv j, b[ djpvj;yjv rjynfrnt c DBX. Lkz dfib[ gfhnythjd df;yj pyfnm> xnj jyb vjukb gjldthuyenmcz rjynfrne c dbhecjv> xnj,s jyb vjukb epyfnm> ,jkmys kb jyb> b bpdktxm gjkmpe bp hfyytq lbfuyjcnbrb b ktxtybz. Dhfx vj;tn gjghjcbnm dfc erfpfnm bvtyf cdjb[ gfhnythjd b cghjcbnm> yt ,eltn kb dfv euhj;fnm jgfcyjcnm d ckexft edtljvktybz b[. D ckexft jnyjitybq c rtv-kb,j bp gfhnythjd> cjghjdj;lfdib[cz ;tcnjrbv j,hfotybtv> df;yj ghtljcnfdbnm ytj,[jlbve/ byajhvfwb/ dhfxe. Lkz gjkextybz ljgjkybntkmyjq byajhvfwbb j, eckeuf[> bvt/ob[ jnyjitybt r yfcbkb/ d ctvmt> gjpdjybnt gj ntktajye 1-800-942-6906.

• Gj pfrjyfv infnf dhfx j,zpfy cjj,obnm ltgfhnfvtyne plhfdjj[hfytybz bvtyf gfhnythjd gfwbtynf !yfcnjzob[ b ghjiks[ ctrcefkmys[ gfhnythjd> drk/xfz ;ty !ve;tq@> b kbw> c rjnjhsvb ds gjkmpjdfkbcm jlybv ighbwtv bkb bukjq@> j rjnjhs[ tve bpdtcnyj.

• Tckb e dfc tcnm lheubt gfhnyths> j rjnjhs[ yt bpdtcnyj dhfxe> ds vj;tnt cjj,obnm tve b[ bvtyf> xnj,s b[ bpdtcnbkb. • Lkz jrfpfybz cjltqcndbz gfwbtyne b dhfxe d edtljvktybb gfhnythjd ceotcnde/n ytcrjkmrj ljcnegys[ fkmnthyfnbd. Tckb ds bkb dhfx

yt gkfybhetnt edtljvkznm dfib[ gfhnythjd> ltgfhnfvtyn plhfdjj[hfytybz vj;tn edtljvbnm b[> yt hfcrhsdfz kbxyjcnb gfwbtynf. Tckb nfrjt edtljvktybt ghtlcnfdkztn hbcr lkz gfwbtynf> ltgfhnfvtyn plhfdjj[hfytybz vj;tn jnkj;bnm edtljvktybt yf gthbjl dhtvtyb> rjnjhjuj ,eltn ljcnfnjxyj lkz njuj> xnj,s gfwbtyn gjkexbk eckeub gj ghtljndhfotyb/ yfcbkbz d ctvmt.

• Tckb ds yt cjj,obnt dhfxe yb jlyjuj bvtyb cdjtuj gfhnythf bkb tckb ceotcndetn ytj,[jlbvjcnm gjlndth;ltybz byajhvfwbb j dfib[ gfhnythf[> nj ltgfhnfvtyn plhfdjj[hfytybz vj;tn cdzpfnmcz c dfvb> xnj,s gjghjcbnm j cjltqcndbb d lfyyjv ghjwtcct.

Rjyabltywbfkmyjcnm htpekmnfnjd ntcnjd yf DBX b lheujq bvt/otq r 'njve jnyjitybt byajhvfwbb Tckb ds cxbnftnt> xnj dfif rjyabltywbfkmyjcnm ,skf yfheityf> bkb tckb ds [jnbnt gjkexbnm ljgjkybntkmye/ byajhvfwb/ j rjyabltywbfkmyjcnb cdtltybq> cdzpfyys[ c DBX> gjpdjybnt gj ntktajye ujhzxtq kbybb gj djghjcfv rjyabltywbfkmyjcnb byajhvfwbb> cdzpfyyjq c DBX> ghb Ltgfhnfvtynt plhfdjj[hfytybz infnf Ym/-Qjhr> yjvth ntktajyf 1-800-962-5065. K/,jt kbwj> ghtljcnfdkz/ott vtlbwbycrbt bkb cjwbfkmyst eckeub> rjnjhjt cjj,obn rjve-kb,j cdtltybz j dfc> cdzpfyyst c DBX> yt bvtz yf 'nj cjjndtncnde/otuj ghfdf> vj;tn ,snm jinhfajdfyj yf cevve lj 5 000 ljkkfhjd b ghbujdjhtyj r n/htvyjve pfrk/xtyb/ yf chjr lj jlyjuj ujlf. Pfrjy nfr;t pfoboftn gfwbtynjd jn lbcrhbvbyfwbb d cdzpb c DBX ghb j,tcgtxtybb ;bkmtv> ecnhjqcndt yf hf,jne> vtlbwbycrjv j,cke;bdfybb b ghtljcnfdktybb ghjxb[ eckeu. Lkz gjkextybz ljgjkybntkmyjq byajhvfwbb gj 'njve djghjce gjpdjybnt d Jnltk gj pfobnt ghfd xtkjdtrf infnf Ym/-Qjhr gj ntktajye 1-800-523-2437.

Z gjkexbkf jndtns yf cdjb djghjcs j ntcnf[ yf fynbntkf r DBX. Z lf/ cjukfcbt yf dsgjkytybt ntcnf yf DBX.

Gjlgbcm% ________________________________________________________________________________________________________ Lfnf% _______________________________________________________________

I provided pre-test counseling in accordance with Article 27-F of the New York State Public Health Law. I answered the above individual’s questions about the test and offered her an unsigned copy of this form.

Signature: _____________________________________________________ Title: ________________________________

Facility/Provider Name: ___________________________________________________________________________________

DOH-4158RUS (6/04) p2 of 2