Approved, SCAO

STATE OF MICHIGAN
JUDICIAL DISTRICT COURT
JUDICIAL CIRCUIT COURT
COUNTY

Court  address

ORDER FOLLOWING HEARING ON
PETITION FOR TESTING OF
INFECTIOUS DISEASE

CASE NO.

Court  telephone  no.

Petitioner's name, address, and telephone no.

Respondent's name, address, and telephone no.

v

1. Date of Hearing:

Judge:

2. A petition has been filed asserting that the individual named above was requested to undergo testing for infectious disease in

Bar no.

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.

7. The individual shall undergo testing for

by

    .

Name of local health department or health care provider

a. The employer shall transport the individual within 24 hours to the agency/facility named above for testing.

HIV
HBV
HCV

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

Judge

MC 74   (3/08)   ORDER FOLLOWING HEARING ON PETITION FOR TESTING OF INFECTIOUS DISEASE

MCL 333.5205(7), (9)