PETITION TO TEST FOR BLOOD-BORNE PATHOGENS Commonwealth of Virginia VA. CODE � 32.1-45.2 Court Case No. General District Court Hearing Date and Time: ADDRESS OF COURT TO ANY AUTHORIZED OFFICER: You are commanded to summon the Respondent, and the Director of the Health Department. TO THE RESPONDENT: You are summoned to appear before this court at the above address on to answer the Petitioner's claim. DATE AND TIME DATE CLERK DEPUTY CLERK MAGISTRATE PETITIONER ADDRESS The undersigned petitioner is: an employee, as that term is defined in Virginia Code � 32.1-45.2(J), of a public safety agency who has potentially been exposed to a blood-borne pathogen and pursuant to Va. Code � 32.1-45.2(B) informed consent for testing has been refused or the individual who is the basis of the exposure is deceased. an agent of a public safety agency whose employee has potentially been exposed to a bloodPETITIONER'S TITLE IF AN AGENT OF A PUBLIC SAFETY AGENCY V. RESPONDENT borne pathogen and pursuant to Va. Code � 32.1-45.2(B) informed consent for testing has been refused or the individual who is the basis of the exposure is deceased. ADDRESS a person potentially exposed to a blood-borne pathogen pursuant to Virginia Code � 32.1-45.2(C) and informed consent for testing of the public safety agency employee has been refused. Therefore, the undersigned petitions this court to determine whether an exposure prone incident, as defined in Va. Code � 32.1-45.2(L) has taken place, and to order testing and disclosure of the test results to me. Date of alleged exposure: Place of alleged exposure: Name and address of the individual whose body fluids I desire to have tested: ATTORNEY FOR THE RESPONDENT: I request testing for Human Immunodeficiency virus, Hepatitis B virus and Hepatitis C virus. Date: ORDER I find by a preponderance of the evidence after being advised by the State Health Commissioner or his designee that an exposure prone incident as defined in Va. Code � 32.1-45.2(L) has occurred, and I order testing for blood-borne pathogens as requested in the petition. The test results shall be disclosed to the petitioner as soon as they are completed. Respondent is ordered to appear at FACILITY NAME ATTORNEY FOR THE PETITIONER: Signature of Petitioner: on DATE at TIME m. for such testing. I do not find by a preponderance of the evidence after being advised by the State Health Commissioner or his designee that an exposure prone incident as defined in Va. Code � 32.1-45.2(L) has occurred, and I order the petition dismissed. I order the record of this case to be sealed. DATE FORM DC-405 PDF (PAGE ONE) 10/97 JUDGE American LegalNet, Inc. www.USCourtForms.com Name Address Name Director of the Address Health Department PERSONAL SERVICE PERSONAL SERVICE Being unable to make personal service, a copy was delivered in the following manner: Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. Being unable to make personal service, a copy was delivered in the following manner: Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) Not Found SERVING OFFICER Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) Not Found SERVING OFFICER for DATE for DATE FORM DC-405, DC-406 (PAGE TWO) PDF 10/97 American LegalNet, Inc. www.USCourtForms.com