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STATE OF MICHIGAN JUDICIAL DISTRICT COURT JUDICIAL CIRCUIT COURT COUNTY
Court address

CASE NO. PETITION FOR TESTING OF INFECTIOUS DISEASE
Court telephone no.

Petitioner name, address, and telephone no.

v

Respondent name, address, and telephone no.

1. I, the employer, make this petition in respect to
Name (type or print)

, who is a

court employee. local corrections officer. county employee. police officer. other individual making lawful arrest.

2. The employee named above received training in the transmission of bloodborne diseases required under MCL 333.5204(1) on at .
Date Place of training

3. On

Date

, the employee named above made a request to me in accordance with be tested for HIV, HBV, and/or HCV
Name of arrestee, correctional facility inmate, parolee, or probationer

MCL 333.5204 that

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 test subject named above. A copy of the request is attached. 4. The proposed test subject refused to undergo one 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.
Date Signature

Attorney signature Name (type or print) Address City, state, zip Telephone no.

MC 72 (3/09)

PETITION FOR TESTING OF INFECTIOUS DISEASE

MCL 333.5204(4), MCL 333.5205(3)