FORM DC-406 (MASTER, PAGE ONE OF TWO) 07/19 PETITION TO REQUIRE BLOOD TESTCommonwealth of VirginiaVa. Code 247 32.1-45.1[ ] General District CourtIn the ...................................................................................................................[ ] Juvenile and Domestic Relations District CourtIn re ..........................................................................................,Petitioner v. .............................................................................................., RespondentThe undersigned petitioner is:[ ] a health care provider or the employee of a health care provider as defined in Va. Code 247 32.1-45.1(C) or (D) who has been directly exposed to the body fluids of a patient,[ ]a patient who has been directly exposed to the body fluids of a health careprovider or employee of a health care provider as defined in Va. Code 247 32.1-45.1(C) or (D),[ ]a law enforcement officer as defined in Va. Code 247 32.1-45.1(G), salaried or volunteer firefighter, or salaried or volunteer emergency medical services provider who has been directly exposed to body fluids, or the exposed person222s employer,[ ]a person who has been directly exposed to the body fluids of a law enforcement officer as defined in Va. Code 247 32.1-45.1(G), salaried or volunteer firefighter, or salaried or volunteer emergency medical services provider. [ ]a school board employee as defined in 32.1-45.1(J) who has been directly exposed to body fluids,or the employee222s employer,[ ]a person who has been directly exposed to the body fluids of a school board employee as defined in Va. Code 247 32.1-45(J), and the person whose blood specimen is sought for testing for infection with human immunodeficiency virus or the hepatitis B or C viruses and who is deemed to have consented to testing [ ] refuses to provide such specimen OR [ ]is a minor whoseparent, guardian, or person standing in loco parentis withholds consent for such specimen to be taken or is not reasonably available.The undersigned petitions this court to order the person to provide a blood specimen or submit to testing and disclose the test results in accordance with the law. Testing for human immunodeficiency virus and the hepatitis B and C virusesis requested.Date and place of the alleged exposure:...........................................................................................................................................................................Name and address of the individual whose blood specimen is sought for testing:...................................................................................................................................................................................................................................................................................................................................................... ....................................................................... DATESIGNATURE OF PETITIONERORDER[ ]I find that there is probable cause to believe that a person identified in Va. Code 247 32.1-45.1 has been exposed in the manner set forth in Va. Code 247 32.1-45.1. I find that the person whose blood specimen is sought for testing for infection with human immunodeficiency virus or the hepatitis B or C viruses and who is deemed to have consented to such testing [ ] refuses to provide such specimen [ ] is a minor whoseparent, guardian, or person standing in loco parentis withholds consent for such specimen to be taken or is not reasonably available. THEREFORE, [ ] upon the advice of the Commissioner of Health or his designee, I order that the person provide a blood specimen or submit to testing and disclose the test results in accordance with Va. Code 247 32.1-45.1. The test results shall be disclosed to the petitioner as soon as they are completed, and both the petitioner and respondent shall receive counseling and opportunity for face-to-face disclosure of any test results by a licensed practitioner or trained counselor.[ ]Respondent is ordered to appear at................................................................................on............................................at................................. for such testing.NAME OF FACILITYDATETIME[ ]I order the petition dismissed. ....................................................................... DATEJUDGE TO ANY AUTHORIZED OFFICER: You are commanded to summon the Respondent, and serve notice on the Director of the......................................................................................................................................................................................................Health Department.TO THE RESPONDENT: You are summoned to appear before this court on ...............................................................................................................................................................................to answer the Petitioner222s claim. DATE AND TIME.......................................................................... DATE[ ] CLERK [ ] DEPUTY CLERK Court Case No. ........................................................................Hearing date and time: .......................................................... PETITION TO REQUIRE BLOOD TEST ..................................................................................................... PETITIONER ADDRESS v. RESPONDENT ADDRESS ATTORNEY FOR THE PETITIONER ATTORNEY FOR THE RESPONDENTServe:..................................................................................................... DIRECTOR OF THE LOCAL HEALTH DEPARTMENT..................................................................................................... ADDRESS..................................................................................................... ..................................................................................................... American LegalNet, Inc. www.FormsWorkFlow.com FORM DC-406 (MASTER, PAGE TWO OF TWO) 10/12 RETURNS: Each person was served according to law, as indicated below, unless not found. NAME.............................................................. ...................................................................... ADDRESS ......................................................... ...................................................................... NAME............................................................. ..................................................................... ADDRESS ........................................................ ..................................................................... NAME ............................................................ Director of the ................................Health Department ..................................................................... ADDRESS ........................................................ ..................................................................... [ ] PERSONAL SERVICE Tel. No. .................................[ ] PERSONAL SERVICE Tel. No. ..................................[ ] PERSONAL SERVICE Tel. No. ................................ Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest)age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. ................................................................. ................................................................. [ ] Posted on front door or such other door as appears to be themain entrance of usual place of abode, address listed above. (Other authorized recipient not found.) Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest)age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above.