Virginia > Statewide > District Court > Civil
Petition To Require Blood Test DC-406 - Virginia
| Petition To Require Blood Test Form. This is a Virginia form and can be used in Civil District Court Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PETITION TO REQUIRE BLOOD TEST Commonwealth of Virginia Va. Code § 32.1-45.1 Court Case No. ........................................................................ Hearing date and time: .......................................................... 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 PETITION TO REQUIRE BLOOD TEST .......................................................................... DATE ___________________________________________________________ [ ] CLERK [ ] DEPUTY CLERK [ ] MAGISTRATE [ ] 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 volunteer firefighter, paramedic or emergency medical technician who has been directly exposed to body fluids, or the exposed person's employer, [ ] a person who has been directly exposed to the body fluids of a law enforcement officer as defined in Va. Code § 32.1-45.1(G), salaried or volunteer firefighter, paramedic or emergency medical technician. [ ] 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 fluids 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 infection 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 minor'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 immunodeficiency virus and hepatitis B and C viruses is requested. Date and place of the alleged exposure: ........................................................................................................................................................................... Name and address of the individual whose blood specimen is sought for testing: .................................................................................................. .................................................................................................................................................................................................................................................... ....................................................................... DATE ..................................................................................................... PETITIONER ..................................................................................................... ADDRESS ..................................................................................................... ..................................................................................................... v. ..................................................................................................... RESPONDENT ..................................................................................................... ADDRESS ..................................................................................................... ..................................................................................................... ..................................................................................................... ATTORNEY FOR THE PETITIONER ..................................................................................................... ATTORNEY FOR THE RESPONDENT _________________________________________________________________ SIGNATURE OF PETITIONER Serve: ..................................................................................................... DIRECTOR OF THE LOCAL HEALTH DEPARTMENT [ ] I find that the person whose blood specimen is sought for testing for infection with human immunodeficiency virus or hepatitis B or C viruses and who is deemed to have consented to such testing [ ] refuses to provide such specimen [ ] is a minor who refuses 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 reasonably 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 shall be disclosed to the petitioner as soon as they are completed, and both the petitioner and respondent shall 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 DATE TIME for
|
|||||||
