Government of Ontario: Ministry of Community Safety and Correctional Services

Form 3 - Respondent Report

Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07

TO BE COMPLETED BY THE RESPONDENT

An application has been made pursuant to the Mandatory Blood Testing Act, 2006 in which you are named as respondent. In the application, the applicant alleges that he or she came into contactwith your bodily substance and wishes to have your blood analysedfor HIV/AIDs, Hepatitis B or Hepatitis C. Details of the occurrence as described in the physician and applicant reports are available from the medical officer of health.

If you do not agree to provide a blood sample voluntarily, the application will be referred to the Consent and Capacity Board and an order may be made by the Board requiring you to allow a physician, medical laboratory technologist or registered nurse (with an extended certificate of registration under the Nursing Act, 1991) to take a blood sample for analysis for HIV/AIDs, Hepatitis B or Hepatitis C in accordance with the Mandatory Blood Testing Act, 2006.

YOU HAVE THE RIGHT TO BE PRESENT AT A HEARING, IF THERE IS ONE, WHETHER OR NOT YOU SUBMIT THIS FORM TO THE CONSENT AND CAPACITY BOARD. IF YOU DO NOT COMPLETE THIS FORM AND SUBMIT IT TO THE CONSENT AND CAPACITY BOARD, THE APPLICATION MAY BE CONSIDERED WITHOUT REGARD TO THE INFORMATION CONTAINED IN THIS FORM.

THIS FORM IS NOT INTENDED TO REPLACE YOUR PRESENCE AT THE HEARING.

Collection, use and disclosure of the personal information on this form is for the consideration of an application under the Mandatory Blood Testing Act, 2006 for an order requiring a respondent to give a blood sample to determine the HIV/AIDS, hepatitis B and/or hepatitis C status of the respondent. The authority for collection and use of this information is the Mandatory Blood Testing Act, 2006. For information about collection practices contact the Corrections and Community Safety Policy Branch, Ministry of Community Safety and Correctional Services at 416 325-7331.

Keep one copy of this form and send one copy by FAX to the Consent and Capacity Board Fax Number: 416 924-8873 or 1 866 777-7273

A . Respondent Information

Name: Last Name
First Name
Middle Initial

Address: Unit Number
Street Number
Street Name
City/Town
Province
Postal Code
Home Telephone
Business Telephone
OHIP number (10 digits)
Version; Sex; Male
Female; Age
Date of birth (yyyy/mm/dd)

Family Physician: Last Name
First Name
Middle Initial; Unit Number
Street Number
Street Name
City/Town
Province
Postal Code
Office Telephone
Office Fax Number

Have you been approached to voluntarily provide information respecting whether you are positive for HIV/AIDS, Hepatitis B and Hepatitis C or to voluntarily provide a blood sample to be tested for these diseases?

No
Yes

explain

If you answered ”No” to the previous question, would you agree to voluntarily provide information respecting whether you are positive for HIV/AIDS, Hepatitis B and Hepatitis C or to voluntarily provide a blood sample to be tested for these diseases?

No
Yes

If an order is made to provide a blood sample, do you want your family physician named on the order?

No
Yes

Do you want the report on the results of the blood analysis to be delivered to your physician?

No
Yes

B. Details of Occurence

In the application, the applicant claims that he or she came into contact with your bodily substance.Do you recall the circumstances where the applicant may have come into contact with your bodily substance?

Explain

Do you recall the date, time and location where the applicant may have come into contact with your bodily substance?

Date (yyyy/mm/dd)
Time
am
pm
Unit Number
Street Number
Street Name
City / town
Province
Postal code

C. Blood Sample Information - Explain any circumstances that might put your health or life in danger if a lood sample is taken from you.

D. Additional Information - Provide any other information you believe may be relevant to the application, including mental anguish, stress or anxiety.

E. Information Accurate

I hereby confirm that the information provided in this form is accurate to the best of my knowledge.

Name of Respondent - please print

Last Name

First Name

Middle Name

Signature

Date (yyyy/mm/dd)