Fill and Sign the Dc 405 Petition to Test for Blood Borne Pathogens Master Pgs1 2 Final 7 08doc Form

PETITION TO TEST BLOOD-BORNE PATHOGENS Court Case No. ........................................................................\ ......... Commonwealth of Virginia VA. CODE § 32.1-45.2 ........................................................................\ ...................................................................................................................... General District Court Hearing Date and Time: ................................................................ ........................................................................\ ...............................................................................................................................\ ....................................... ........................................................................\ .................................... PETITIONER ........................................................................\ .................................... ADDRESS ........................................................................\ .................................... ........................................................................\ .................................... PETITIONER’S TITLE IF AN AGENT OF A PUBLIC SAFETY AGENCY v. ........................................................................\ .................................... RESPONDENT ........................................................................\ .................................... ADDRESS ........................................................................\ .................................... ........................................................................\ .................................... ATTORNEY FOR THE PETITIONER: ........................................................................\ .................................... ATTORNEY FOR THE RESPONDENT: ........................................................................\ .................................... ADDRESS OF COURT TO ANY AUTHORIZED OFFICER: You are commanded to summon the Respondent, and the ........................................................................\ .......................................................................................... Health Department. TO THE RESPONDENT: You are summoned to appear before this court at the above address on ........................................................................\ .................................... to answer the Petition’s claim. DATE AND TIME ....................................................................... _____________________________________________________ DATE [ ] CLERK [ ] DEPUTY CLERK [ ] MAGISTRATE The undersigned petitioner is: [ ] an employee, as that term is defined in Virginia Code § 32.1-45.2(J), of the public safety agency who has potentially been exposed to a blood-borne pathogen and pursuant to Va. Code § 32.1-45.2(B) consent for testing has been refused or the individual who is the basis of the exposure is deceased and consent for testing has been refused by decedent’s next of kin. [ ] an agent of a public safety agency whose employee ........................................................................\ .... has potentially been exposed to a blood-borne pathogen and pursuant to Va. Code § 32.1-45.2(B) consent for testing has been refused or the individual who is the basis of the exposure is deceased and consent for testing has been refused by the decedent’s next of kin. [ ] a person potentially exposed to a blood-borne pathogen pursuant to Virginia Code § 32.1-45.2(C) and consent for testing of the public safety agency employee has been refused. Therefore, the undersigned petitions this court to determin e whether an exposure prone incident, as defined in Va. Code § 32.1-45.2(L) has occurred, 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: ........................................................................\ ........ ........................................................................\ ...............................................................................................................................\ ....................................... I request testing for [ ] Human Immunodeficiency virus [ ] Hepatitis B virus [ ] Hepatitis C virus. Date: ..................................................................... Signature of Petitioner: ___________________________________________ ORDER [ ] I find by a preponderance of the evid ence 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 pa thogens 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 ........................................................................\ ............................................... on ........................................................................\ . at ................................. m. for such testing. FACILITY NAME DATE TIME [ ] 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 JUDGE FORM DC-405 (MASTER, PAGE ONE OF TWO) 07/08 RETURNS: Each person was served according to law, as indicated below, unless not found. NAME.............................................................. ...................................................................... ADDRESS ......................................................... ...................................................................... NAME ............................................................. Director of the ................................ Health Department ...................................................................... ADDRESS ......................................................... ...................................................................... [ ] 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 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 .................... for_____________ ____________________ DATE ..................... for____________________________________ DATE FORM DC-405 (MASTER, PAGE TWO OF TWO) 10/97