SOP 215.02-att-1: Special Conditions of Work Release for HIV-Infected Residents

SOP 215.02
Attachment 1
1/30/20
Page 1 of 2
# Special Conditions for Work Release for HIV-Infected Residents

1. I shall demonstrate through oral or written examination that I have been educated

regarding my medical condition and its implications in my life. I understand the correct
procedure for disposal or cleansing of physical objects soiled with my body wastes or
fluids of any type. I accept my moral and ethical duties to others as well as myself in
refraining from activities, which could spread the disease as defined by accepted and
current medical authorities.

2. I will permit the disclosure of my medical condition to my spouse. Failure to do so will

result in denial of all passes and leave. I am aware that I may ask the Center's Health Care
Provider (if any) to help me disclose my condition to my spouse.

3. I will have regular medical examinations by a physician who is aware of my medical

condition. My physician will notify my Superintendent in writing if my condition
becomes such that I am not capable of working or if there are any other medical
limitations, which restrict my participation in the work place. I agree to sign a release of
information form that will allow my Superintendent access to any medical information
concerning my condition during the period I am in the program.

4. I will not engage in sexual practices, which have been identified by accepted medical

sources as unsafe sexual practices for persons with the HIV-infection.

5. I will not donate or sell blood, plasma or organs under any circumstances while a resident

of the Center.

6. I will cooperate with public health officials who monitor HIV-infection cases in Georgia.

7. I will refrain from use of alcohol and all non-prescribed controlled substances and from

the use of prescribed drugs except as recommended by my doctor.

8. I will refrain from IV needle use, unless prescribed by my doctor. I will safely dispose of

any used needle or syringe.

9. I will refrain from any tattooing activity.

10. I am aware that under O.C.G.A. § 16-5-60(c), it is a felony to knowingly participate in

sexual activity, share needles, or donate blood/blood products, without first disclosing my
HIV-positive status to the person(s) involved.

Retention Schedule: Upon completion, this form shall be placed in the Medical File and retained
according to the official records retention schedule for that file.

SOP 215.02
Attachment 1
1/30/20
Page 1 of 2

# ACKNOWLEDGEMENT

I understand that the Special Conditions for HIV-Infected Transitional Center WorkRelease Residents have been given to me as a separate document in order to protect my
privacy. I know that I am obligated to obey all of the Special Conditions, and my
signature on this form expresses my awareness of the Special Conditions, and my promise
to obey all of the Special Conditions.

Signed this _______________ day of _________________, 20_____.

Signed: ___________________________________ I.D. Number: _______________
Resident

Signed: ___________________________________
Witness

Retention Schedule: Upon completion, this form shall be placed in the Medical File and retained
according to the official records retention schedule for that file.