During an immigration medical examination, panel physicians use this one-page form to confirm that a client who tested HIV-positive, or disclosed HIV-positive status, received counselling. The client acknowledges discussion of their status, risk reduction to prevent transmission, and the importance of contacting local public health in Canada for care. The signed form goes with the IME, which is graded B.
The panel physician completes and signs the form, recording whether positive status was confirmed by IME testing or self-report and whether a referral to an HIV expert was offered and initiated or declined. The client, or their guardian if applicable, signs the acknowledgement.
Download the current version from the source each time; forms change without notice.
Confirmation of Counselling after HIV Positive Test or Status Disclosure
IRCC takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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For every immigration medical examination client with a positive HIV test or who self-reports HIV-positive status. IRCC grades all such IMEs B and requires the signed and dated IMM 5728 with them, along with hepatitis B and C screening and the antiretroviral regimen.
Both the client (or their guardian, if applicable) and the panel physician. The client's signature acknowledges discussion of their HIV-positive status, risk-reduction strategies and contacting local public health in Canada, while the physician records the follow-up care offered and signs.