Fill and Sign the Dc 405 Petition to Test for Blood Borne Pathogens Master Form

PETITION TO REQUIRE BLOOD TEST Commonwealth of Virginia Va. Code § 32.1-45.1[ ] General District Court In the ................................................................................................................... [ ] Juvenile and Domestic Relations District Court In re .......................................................................................... ,Petitioner v. .............................................................................................. , Respondent The undersigned petitioner is: [ ] a health care provider or the employee of a health care provider as defined in Va. Code § 32.1-45.1(C) or (D) who has been directly exposed to the body fluids of a patient, [ ] a patient who has been directly exposed to the body fluids of a health care provider or employee of a health care provider as defined in Va. Code § 32.1-45.1(C) or (D), [ ] a law enforcement officer as defined in Va. Code § 32.1-45.1(G), salaried or volunte er firefighter, or salaried or volunteer emergency medical services provider who has been directly exposed to body fluids, or the exposed person’s employer, [ ] a person who has been directly exposed to the body flui ds of a law enforcement officer as defined in Va. Code § 32.1-45.1(G ), salaried or volunteer firefighter, or salaried or volunteer emergency medical services provider. [ ] a school board employee as defined in 32.1-45.1(J) who has been directly exposed to body fluids, or the employee’s employer, [ ] a person who has been directly exposed to the body flui ds of a school board employee as defined in Va. Code § 32.1-45(J), and the person whose blood specimen is sought for testing for infe ction with human immunodeficiency virus or hepatitis B or C viruses and who is deemed to have consented to testing [ ] refuses to provide such specimen OR [ ] is a minor who refuses to provide such specimen and the mi nor’s parent, guardian, or person standing in loco parentis also withholds consent for such specimen to be taken or is not reasonably available. The undersigned petitions this court to order the person to provide a blood specimen or submit to testing and disclose the test results in accordance with the law. Testing for human immunodeficien cy virus and hepatitis B and C viruses is requested. Date and place of the alleged exposure: ........................................................................................................................................................................... Name and address of the individual w hose blood specimen is sought for testing: .................................................................................................. .................................................................................................................................................................................................................................................... ....................................................................... _________________________________________________________________ DATE SIGNATURE OF PETITIONER ORDER [ ] I find that the person whose blood specimen is sought for te sting for infection with human immunodeficiency virus or hepati tis B or C viruses and who is deemed to have consented to such testing [ ] refuses to provide such specimen [ ] is a minor who refu ses to provide such specimen and the minor’s parent, guardian, or person standing in loco parentis also withholds consent for such specimen to be taken or is not reasona bly available. THEREFORE, upon the advice of the Commissioner of Health or his designee, I order that the person provide a blood specimen or submit to testing and disclose the test results in accordance with Va. Code § 32.1-45.1 as requested in the petition. The test results sh all be disclosed to the petitioner as soon as they are completed, and both the petitioner and respondent sha ll receive counseling and opportunity for face -to-face disclosure of any test results by a licensed practitioner or trained counselor. [ ] Respondent is ordered to appear at ................................................................................ on............................................ at................................. NAME OF FACILITY DATETIME for such testing. [ ] I order the petition dismissed. [ ] I order the record of this case to be sealed. ....................................................................... __________________________________________________________________ DATE JUDGE 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 Court Case No. ........................................................................ Hearing date and time: .......................................................... PETITION TO REQUIRE BLOOD TEST ..................................................................................................... PETITIONER ..................................................................................................... ADDRESS ..................................................................................................... ..................................................................................................... v. ..................................................................................................... RESPONDENT ..................................................................................................... ADDRESS .......................................................................................................................................................................................................... ..................................................................................................... ATTORNEY FOR THE PETITIONER ..................................................................................................... ATTORNEY FOR THE RESPONDENT Serve: ..................................................................................................... DIRECTOR OF THE LOCAL HEALTH DEPARTMENT ..................................................................................................... ADDRESS ..................................................................................................... ..................................................................................................... FORM DC-406 (MASTER, PAGE ONE OF TWO) 07/15 FORM DC-406 (MASTER, PAGE TWO OF TWO) 10/12 RETURNS: Each person was served according to law, as indicated below, unless not found. NAME.............................................................. ...................................................................... ADDRESS ......................................................... ...................................................................... NAME............................................................. ..................................................................... ADDRESS ........................................................ ..................................................................... NAME ............................................................ Director of the ................................ Health Department ..................................................................... ADDRESS ........................................................ ..................................................................... [ ] PERSONAL SERVICE Tel. No. ................................. [ ] PERSONAL SERVICE Tel. No. .................................. [ ] PERSONAL SERVICE Tel. No. ................................ 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.) 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.) Being unable to make personal servi ce, 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 [ ] NOT FOUND ________________________________ SERVING OFFICER [ ] NOT FOUND __________________________________ SERVING OFFICER .................... for ____________ _____________________ DATE .................... for ____________ _____________________ DATE .................... for ____________ _______________________ DATE