Annexure-1
Sample Consent Form for VIA
I have been explained in detail about the VIA test for prevention and early detection of cancer in the
mouth of my womb (uterine cervix) . The advantages and the purpose of these tests have been clarified
to me.
I understand that the mouth of my cervix will be examined after application of 5% acetic acid to detect
or to exclude pre cancer or cancer. I understand that these procedures are generally harmless, but may
occasionally cause some irritation or mild bleeding, which can be easily controlled.
I understand that, if the VIA test is positive, I might have to undergo further tests to confirm and I will
be managed accordingly.
I understand that a negative screening does not rule out the possibility of developing these diseases later.
I need to contact the health facility at the earliest, whenever I have any symptoms/warning
signs/complaints listed in the IEC materials provided and explained to me.
I hereby express my willingness to undergo the above tests and treatment, if advised.
Signature of the individual: Health care provider’s name & signature
Name: Date:
Date:
Screening ID:
Address:
ICMR-NICPR | Training manual on visual inspection with acetic acid (VIA) pg. | 19
Annexure-2
VIA Reporting Chart
1. Screening ID: _______________ 2. Name: _______________________
3. Age: ______ 4. Center name_____________________
5. District_______________________ 6. Date of visit: ____ /____ /____(Day/Month/Year)
7.Parity____________________
8. Do you have any of these following symptoms? (Tick whichever is applicable)
a) Excessive vaginal discharge e) Itching in the external anogenital region
b) Ulcers in the external anogenital region f) Lower abdominal pain
c) Pain during sexual intercourse g) Bleeding after intercourse
d) Intermenstrual bleeding h) Low back ache
9. Visual examination findings (per speculum) (Tick whichever is applicable)
a) Squamocolumnar junction fully seen e) Cervical polyp
b) Nabothian follicles f) Cervicitis
c) Leukoplakia g) Condyloma
d) Growth
10. Findings one minute after application of 5% acetic acid (VIA)
a) VIA Negative
b) VIA Positive
c) invasive cancer
11. In case of VIA positive lesion, does the acetowhite lesion extend into the endocervical canal? (Skip
this question in case of VIA negative)
a) Yes
b) No
12. In case of VIA positive lesion, number of quadrants involved
a) One
b) Two
c) Three
d) Four
13. Findings after application of Lugol’s iodine (VILI)
a) Negative
b) Positive
c) invasive cancer
14.Draw the location of VIA positive & VILI positive
VIA VILI
_____________________________
Signature of the health care provider
ICMR-NICPR | Training manual on visual inspection with acetic acid (VIA) pg. | 20
