Approved, SCAO Original - Court 1st copy - Prosecuting attorney or victim advocate 2nd copy - Defendant/Juvenile 3rd copy - Testing agency/Physician STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT Court address CASE NO. ORDER FOR COUNSELING AND TESTING FOR DISEASE/INFECTION Court telephone no. The State of Michigan THE PEOPLE OF v Defendant's/Juvenile's name, address, and telephone no. Juvenile In the matter of 1. On Date defendant/juvenile was arraigned on a warrant for: defendant was assigned to youthful trainee status for: defendant/juvenile was convicted of: defendant/juvenile was bound over to the circuit court for: juvenile was found to be within the provisions of MCL 712A.2 for violation of: . Specify (See reverse side for list of violations.) 2. The defendant/juvenile is IT IS ORDERED: on bond incarcerated in . 3. The defendant/juvenile shall receive counseling regarding venereal disease, hepatitis B and C infection, human immunodeficiency virus (HIV) infection; acquired immunodeficiency syndrome; and acquired immunodeficiency syndrome related complex including, at a minimum, information regarding treatment, transmission, and protective measures from a local health department, at the defendant's/juvenile's expense, an assigned counseling and testing agency, at the defendant's/juvenile's expense, a licensed physician, at the defendant's/juvenile's expense, . Name of physician or contact person of agency or health department and address 4. The defendant/juvenile shall be confidentially tested for venereal disease, hepatitis B and C infection, and for the presence of HIV or an antibody to HIV from the agency or person providing the counseling. The person or agency administering the test shall transmit the test results and any other medical information obtained from the defendant/juvenile to this court. The test results will be made part of the court record but are confidential and shall be disclosed only to those specified in the statute. 5. If authorized by the victim or victim's representative, the victim advocate of the prosecuting office shall immediately forward the name, address, and telephone number of the victim or the victim's representative to the physician or agency administering the test on the defendant/juvenile. 6. All testing and counseling of the defendant/juvenile must be completed and test results transmitted to the court before the sentencing/dispositional hearing date on . within 30 days of this order. . Test results must be transmitted to the circuit court at this court at the address stated above. Failure to comply may result in penalty for contempt of court. Date Judge/Magistrate Bar no. See the other side for instructions and a list of persons subject to testing and counseling under MCL 333.5129. MC 234 (3/13) ORDER FOR COUNSELING AND TESTING FOR DISEASE/INFECTION MCL 333.5129, MCL 333.5131 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS 1. Even if the defendant is convicted of a lesser offense, this form is to be used under MCL 333.5129 to order testing and counseling when a · defendant is arraigned on a warrant in the district court or bound over to circuit court for specific sex offenses as listed below when the district court determines there is reason to believe the violation involved sexual penetration or exposure to a body fluid of the defendant. · defendant is convicted of, or assigned to youthful trainee status for, specific sex offenses as listed below; or · juvenile is found to come under the provisions of MCL 712A.2 for violation of specific sex offenses as listed below. 2. Item 5 applies only if the victim has consented to the release of his/her name, address, and phone number on Department of Community Health form DCH 1253. PERSONS SUBJECT TO TESTING AND COUNSELING UNDER MCL 333.5129 MCL 333.5129(1): An individual arrested and charged with violating one of the following sections of the penal code, or a local ordinance prohibiting prostitution or engaging or offering to engage the services of a prostitute may, upon order of the court, be examined or tested to determine whether the individual has venereal disease, hepatitis B infection, hepatitis C infection, HIV infection, or acquired immunodeficiency syndrome. Examination or test results that indicate the presence of venereal disease, hepatitis B infection, hepatitis C infection, HIV infection, or acquired immunodeficiency syndrome shall be reported to the defendant and, pursuant to sections 5114 and 5114a, to the department and the appropriate local health department of partner notification. MCL 750.448 Soliciting and accosting MCL 750.449 Admitting to place for purpose of prostitution MCL 750.449a Engaging services for purpose of prostitution, lewdness, or assignation, offer to engage; penalty MCL 750.450 Aiders and abettors MCL 750.452 House of ill fame, keeping, maintaining or operating MCL 750.455 Pandering MCL 333.5129(3): If a defendant is bound over to circuit court for a violation of one of the following sections of the penal code and the district court determines there is reason to believe the violation involved sexual penetration or exposure to a body fluid of the defendant, the district court shall order the defendant to be examined or tested for venereal disease, hepatitis B infection, and hepatitis C infection and for the presence of HIV or an antibody to HIV. MCL 750.145a Accosting, enticing, or soliciting child for immoral purposes MCL 750.338 Gross indecency; between male persons MCL 750.338a Gross indecency; between female persons MCL 750.338b Gross indecency; between male and female persons MCL 750.450 Aiders and abettors MCL 750.452 House of ill fame, keeping, maintaining or operating MCL 750.455 Pandering MCL 750.520b First-degree criminal sexual conduct MCL 750.520c Second-degree criminal sexual conduct MCL 750.520d Third-degree criminal sexual conduct MCL 750.520e Fourth-degree criminal sexual conduct MCL 750.520g Assault with intent to commit criminal sexual conduct MCL 333.5129(4): Except as otherwise provided in this section, upon conviction of a defendant or the issuance of an order adjudicating a child to be within the provisions of MCL 712A.2, for violating one of the following sections of the penal code, or by intravenously using a controlled substance, or a local ordinance prohibiting prostitution, solicitation, gross indecency, or the intravenous use of a controlled substance, the court having jurisdiction of the criminal prosecution or