Form CDPH8459 "Report of Request and Decision for HIV, Hep B, and/or Hep C Testing" - California

What Is Form CDPH8459?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8459 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8459 "Report of Request and Decision for HIV, Hep B, and/or Hep C Testing" - California

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State of California - Health and Human Services Agency
California Department of Public Health
REPORT OF REQUEST AND DECISION FOR HIV, HEP B, AND/OR HEP C TESTING
The information on this form is being requested pursuant to Title 8 (commencing with Section 7500, including 7510) of Part 3 of the Penal Code.
California law requires a law enforcement employee and/or inmate to report the incident within two calendar days.
When completing this form, if a typewriter is not accessible, please print in a legible manner. Upon completion, this form shall be directed to the chief
medical officer of the correctional facility.
1. Name of Person Reporting Incident:
2. Title (if employee):
3. Location Where Incident Occurred:
4. Business Phone (if appropriate):
5. Name and Address of Correctional Institution (mailing address if different):
6. Date and Time Incident Occurred:
7. Name, Address, Telephone Number, and Statement from Person(s) involved in, or Witness to, the Incident. (Please use separate sheet if necessary.)
8. Description of Incident or Exposure. Please describe fully the event(s) that resulted in the injury or exposure. Tell what happened and how it happened.
Describe the exact location, or description, of injury or exposure. (Please use separate sheet if necessary.)
9. State the nature of exposure (e.g., contact with bodily fluids through altercation, sexual activity, etc.). Include type of bodily fluids exchanged (e.g., blood,
semen, vaginal secretions, saliva. (Please use separate sheet if necessary.)
10. Please name: (1) the person who is the subject of the report and (2) person requesting the test. In the case of a minor, please include (3) the name of the
staff member filing the report on minor’s behalf:
CDPH 8459 (05/18)
Page 1 of 2
State of California - Health and Human Services Agency
California Department of Public Health
REPORT OF REQUEST AND DECISION FOR HIV, HEP B, AND/OR HEP C TESTING
The information on this form is being requested pursuant to Title 8 (commencing with Section 7500, including 7510) of Part 3 of the Penal Code.
California law requires a law enforcement employee and/or inmate to report the incident within two calendar days.
When completing this form, if a typewriter is not accessible, please print in a legible manner. Upon completion, this form shall be directed to the chief
medical officer of the correctional facility.
1. Name of Person Reporting Incident:
2. Title (if employee):
3. Location Where Incident Occurred:
4. Business Phone (if appropriate):
5. Name and Address of Correctional Institution (mailing address if different):
6. Date and Time Incident Occurred:
7. Name, Address, Telephone Number, and Statement from Person(s) involved in, or Witness to, the Incident. (Please use separate sheet if necessary.)
8. Description of Incident or Exposure. Please describe fully the event(s) that resulted in the injury or exposure. Tell what happened and how it happened.
Describe the exact location, or description, of injury or exposure. (Please use separate sheet if necessary.)
9. State the nature of exposure (e.g., contact with bodily fluids through altercation, sexual activity, etc.). Include type of bodily fluids exchanged (e.g., blood,
semen, vaginal secretions, saliva. (Please use separate sheet if necessary.)
10. Please name: (1) the person who is the subject of the report and (2) person requesting the test. In the case of a minor, please include (3) the name of the
staff member filing the report on minor’s behalf:
CDPH 8459 (05/18)
Page 1 of 2
State of California - Health and Human Services Agency
California Department of Public Health
PLEASE REFER TO PENAL CODE SECTION 7511, SUBDIVISION (B) FOR DIRECTION ON CONSIDERING THE FACTS AND CIRCUMSTANCES
TO DETERMINE WHETHER THERE IS A SIGNIFICANT RISK THAT THE INDIVIDUAL WAS EXPOSED TO HIV, HEP B, OR HEP C.
ANY WILLFUL FALSE REPORTING IN CONJUNCTION WITH A REPORT OR A REQUEST FOR TESTING AND/OR ANY WILLFUL USE OR
DISCLOSURE OF TEST RESULTS OR CONFIDENTIAL INFORMATION IN VIOLATION OF ANY OF THE PROVISIONS IN TITLE 8 (COMMENCING
WITH SECTION 7500) OF PART 3 OF THE PENAL CODE IS A MISDEMEANOR.
Signature of Person Reporting Incident:
Date Report was Filed:
The above request was reviewed by:
(Name of Authorized Person)
on
(Title of Authorized Person)
(Date of Review)
It has been determined, by the authorized person, that testing of the above named individual for the following diseases is necessary
considering all the facts and circumstances described in Sections 8 and 9:
Should be conducted for the
Should NOT be conducted at this
Human Immunodeficiency Virus (HIV)
following reason(s):
time, for the following reason(s):
Should be conducted for the
Should NOT be conducted at this
Hepatitis B Virus (HBV)
following reason(s):
time, for the following reason(s):
Should be conducted for the
Should NOT be conducted at this
Hepatitis C Virus (HCV)
following reason(s):
time, for the following reason(s):
Signature of Authorized Person:
Date:
CDPH 8459 (05/18)
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