Approved, SCAO

STATE OF MICHIGAN
JUDICIAL DISTRICT COURT
JUDICIAL CIRCUIT COURT
COUNTY

Court  address

PETITION FOR TESTING OF
INFECTIOUS DISEASE AND
WAIVER OF NOTICE OF HEARING

CASE NO.

Court  telephone  no.

Petitioner name, address, and telephone no.

Respondent name, address, and telephone no.

v

1. I, the employer, make this petition in respect to

Name (type or print)

court employee.        local corrections officer.
police officer.

 other individual making lawful arrest.

    county employee.

         , who is a

Date

3. On

Date

 MCL 333.5204 that

2. The employee named above received training in the transmission of bloodborne diseases required under MCL 333.5204(1) on

at

Place of training

.

         , the employee named above made a request to me in accordance with

Name of arrestee, correctional facility inmate, parolee, or probationer

be tested for HIV, HBV, and/or HCV

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

Attorney signature

Name (type or print)

Signature

Address

City, state, zip

WAIVER OF NOTICE OF HEARING

Telephone no.

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

Date

Signature  of  respondent/Test  subject

Date

MC 72   (3/10)   PETITION FOR TESTING OF INFECTIOUS DISEASE

MCL 333.5204(4), MCL 333.5205(3)