Petition For Testing Of Infectious Disease {MC 72}

Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL DISTRICT COURT PETITION FOR TESTING JUDICIAL CIRCUIT COURT OF INFECTIOUS DISEASE COUNTY Court address Court telephone no.In the matter of 1. I, , the employer, make this petition in respect to, Name (type or print) , who is a court employee. local corrections officer. Name (type or print) county employee. police officer. other individual making lawful arrest. 2. The above named employee received training in the transmission of bloodborne diseases required under MCL 333.5204(1) on at . Date Place of training 3. On , the above named employee made a request to me in accordance with Date MCL 333.5204 that be tested for HIV, HBV, and/or HCV Name of arrestee, correctional facility inmate, parolee, or probationer infection because the employee determined that he/she had sustained a percutaneous, mucous membrane, or open wound exposure to the blood or body fluids of the above named test subject. A copy of the request is attached. 4. The proposed test subject refused to undergo 1 or more of the tests specified in the request. 5. The reasons for the determination that exposure, as described in the attached request, could have transmitted HIV, HBV, and or HCV are: (include a description of the exposure to blood or other body fluids) I REQUEST: 6. A hearing be held and the court find that the allegations are true. 7. The court order the test subject to undergo testing for HIV, HBV, and/or HCV infection under MCL 333.5205. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Attorney signature Petitioner signature Name (type or print) Name (type or print) Address Address City, state, zip Telephone no. City, state, zip Telephone no. Do not write below this line - For court use only MCL 333.5204(4); MSA 14.15(5204)(4),MC 72 (5/00) PETITION FOR TESTING OF INFECTIOUS DISEASE MCL 333.5205(3); MSA 14.15(5205)(3)