JUVENILE MATTERS REQUEST BY VICTIM TO TEST CHILD FOR AIDS/HIV To: The Superior Court for Juvenile Matters Instructions To Victim: Forward completed original and 3 copies of this form to the clerk of court. Keep a copy for your records. Instructions To Clerk: Maintain original in the court file. Provide one copy to the State's Attorney and one copy to the child's attorney. Address of court (Number, street, town and zip code) Docket number STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov JD-JM-185 New 10-10 C.G.S. §§ 19a-581 to 19a-585, 54-102a, 54-102b P.A. 10-43 §41-42 Name of Respondent child Crime(s) charged against Respondent child Name of victim Address to which notice to victim is to be sent Request That the Respondent Child Be Tested for AIDS/HIV I, the victim signing below, make the following statements and request: ("X" all that apply) 1. The child named above is accused of violating section 53a-70 (sexual assault, 1st degree) 53a-70a (aggravated sexual assault, 1st degree) 53a-70b (sexual assault in a spousal or cohabiting relationship) 53a-71 (sexual assault, 2nd degree) a violation of section 53-21 (injury or risk of injury to a child) 53a-72a (sexual assault, 3rd degree) 53a-72b (sexual assault, 3rd degree with a firearm) 53a-73a (sexual assault, 4th degree) 2. I am the victim of the crime. 3. I request that the child named above be tested: ("X" one or both) As soon as possible Upon the court entering a conviction of the child as delinquent for AIDS or HIV (the presence of the etiologic agent for acquired immune deficiency syndrome or human immunodeficiency virus) and that I be told the results. I have read the above and understand it. I agree to the statements above. Signed (Victim/Consented to by Parent or Guardian of minor Victim/Attorney for Victim) Date signed Order Of The Court It is ordered by the court: Request Denied. Request Granted. (C.G.S. § 54-102b requires granting request if the child is convicted as delinquent.) If the child is convicted as delinquent, the Court Support Services Division of the Judicial Branch or the Department of Children and Families is hereby ordered to have the child named above tested for the presence of the etiologic agent for acquired immune deficiency syndrome or human immunodeficiency virus and to perform the test in consultation with the Department of Public Health. The provisions of sections 19a-581 to 19a-585, inclusive, and section 19a-590 of the general statutes, except the requirement that the subject of an HIV-related test provide informed consent prior to the performance of such test and except any provision that would prohibit or limit disclosure of the results of such test to the victim, the court or the Department of Public Health if so ordered below, shall apply to the test ordered and the disclosure of the results of such test. If the child is not convicted as delinquent, the child shall forthwith select a Department of Public Health testing site from a list provided by the clerk of the court and the testing site is hereby ordered to have the child named above tested for the presence of the etiologic agent for acquired immune deficiency syndrome or human immunodeficiency virus. The provisions of sections 19a-581 to 19a-585, inclusive, and section 19a-590 of the general statutes, except the requirement that the subject of an HIV-related test provide informed consent prior to the performance of the test and except any provision that would prohibit or limit disclosure of the results of the test to the victim, the court or the Department of Public Health if so ordered below, shall apply to the test ordered and the disclosure of the results of such test. The results of such test Shall Shall not be disclosed to the victim. (C.G.S. § 54-102b as amended by P.A. 10-43 §41-42 requires disclosure of results to the victim if the child was convicted as delinquent. C.G.S. § 54-102a as amended by P.A. 10-43 §41-42 makes disclosure discretionary with the court if the child is accused but not convicted as delinquent.) A report of the results of such test shall be filed with the Department of Public Health, on a form supplied by it, and filed with this court. ("X" only if the child is accused but not convicted as delinquent.) By order of the court (Print or type name of Judge) Signed (Judge) Date signed American LegalNet, Inc. www.FormsWorkFlow.com