5125 Form

______________ PUBLIC SCHOOLS

_____________, Connecticut

   RELEASE OF CONFIDENTIAL HIV-RELATED INFORMATION

I hereby authorize ___________________________________________ to release confidential

                             [name of individual who holds the information]

HIV-related information, as defined in Connecticut General Statute §19a-581, concerning

________________________________________ to the following personnel:

[name of protected individual]

1.  School Nurse

2.  School Administrator(s)

a.  __________________________________

b.  __________________________________

3.  Student's Teacher(s)

a.  ___________________________________

b.  ___________________________________

4.  Paraprofessional(s)

5.  Director of Pupil Personnel Services

6.  Other(s)

a.  ____________________________________

b.  ____________________________________

This authorization shall be valid for:

1.  [ ]  The student's stay at _____________________________ School

2.  [ ]  The current school year

3.  [ ]  Other ____________________________ (specify period)

I provide this information based on my responsibility to consent for the health care of __________________________________________. I understand that such information shall be held confidential by the persons authorized here to receive such information, except as otherwise provided by law.

____________________________________

Name

____________________________________

Relationship to Student

____________________________________

Date