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Petition For Testing Of Infectious Disease Form. This is a Michigan form and can be use in Infectious Disease Statewide.
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Tags: Petition For Testing Of Infectious Disease, MC 72, Michigan Statewide, Infectious Disease
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)
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