Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT COURT JUDICIAL CIRCUIT COURT COUNTY CASE NO. PETITION FOR TESTING OF INFECTIOUS DISEASE AND WAIVER OF NOTICE OF HEARING Court address 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 , who is a Name (type or print) court employee. police officer. local corrections officer. county employee. 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 3. On Place of training , the employee named above made a request to me in accordance with Date MCL 333.5204 that be tested for HIV, HBV, and/or HCV Name of arrestee, correctional facility inmate, parolee, or probationer 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 Address Name (type or print) City, state, zip Telephone no. WAIVER OF NOTICE OF HEARING We understand that the respondent has the right to be present at the hearing and to cross-examine witnesses and to be represented by an attorney at all stages of the proceedings. We further understand that if the respondent wants an attorney, the respondent should hire one immediately so that he/she will be prepared on the hearing date, and that if the respondent is unable to pay the cost of an attorney, the court will appoint an attorney for the respondent. We waive notice of the hearing and consent to the court hearing the petition immediately. Signature of petitioner Signature of respondent/Test subject Date Date MC 72 (3/10) PETITION FOR TESTING OF INFECTIOUS DISEASE MCL 333.5204(4), MCL 333.5205(3) American LegalNet, Inc. www.FormsWorkFlow.com