Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT COURT JUDICIAL CIRCUIT COURT COUNTY ORDER FOLLOWING HEARING ON PETITION FOR TESTING OF INFECTIOUS DISEASE CASE NO. Court address Petitioner's name, address, and telephone no. 1. Date of Hearing: Court telephone no. v Respondent's name, address, and telephone no. Judge: Bar no. 2. A petition has been filed asserting that the individual named above was requested to undergo testing for infectious disease in accordance with MCL 333.5205 and refused to do so. 3. Notice of hearing has been given according to law. THE COURT FINDS: 4. The allegations of the petition have not been proven by clear and convincing evidence. 5. By clear and convincing evidence that the individual has refused to comply with the request for testing, that the employee, officer, or arresting individual named in the petition sustained a percutaneous, mucous membrane, or open wound exposure to the blood or body fluids of the individual, and that the individual named above could have transmitted HIV, HBV, and/or HCV to the employee, officer, or arresting individual. IT IS ORDERED: 6. The petition is dismissed. HIV HBV by Name of local health department or health care provider HCV a. The employer shall transport the individual within 24 hours to the agency/facility named above for testing. 7. The individual shall undergo testing for . b. A representative of the agency or facility shall within 24 hours come to where the individual is held or housed to take blood or other body fluid sample for testing. c. The local health department or designated health care provider that performs the test(s) may charge the reasonable and customary charges for each test. The individual named above shall pay the cost associated with implementing this order including the charges for each test. d. Within two days after the test results are obtained, the local health department or designated health care provider shall transmit the test results directly to the employee, officer, or arresting individual or, upon request, to his or her primary care physician or another health professional. Date MC 74 (3/08) Judge ORDER FOLLOWING HEARING ON PETITION FOR TESTING OF INFECTIOUS DISEASE MCL 333.5205(7), (9) American LegalNet, Inc. www.FormsWorkflow.com