Free (pc110.pdf) - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTY

PETITION AND EX PARTE ORDER FOR TRANSPORT AND/OR TEMPORARY DETENTION

CASE NO.

In the matter of PETITION local health officer State Community Health Department representative and make a minor , who is an adult and who resides in

1. I,
Name (type or print)

, am a
Name (type or print)

this affidavit in respect to, County at
Address

City

and who is presently found at
State Zip Address, location, or facility

.

2. An emergency exists and there is reasonable cause to believe that the individual is a carrier and a health threat to others for the reasons stated in the attached affidavit. I REQUEST: 3. the individual be taken into custody and transported to
Name of facility

, examination. testing. diagnosis. treatment.

an emergency care or treatment facility, for

observation.

4. the individual be detained temporarily at the facility and a hearing be held within the next 72 hours to determine whether temporary detention should continue up to five days, and longer if a petition for treatment of an infectious disease is filed within that five days. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Date Signature Name (type or print) Address City, state, zip Telephone no.

ORDER THE COURT FINDS: 5. An affidavit has been filed in compliance with Section 5207 of the Public Health Code. 6. Reasonable cause exists to believe that there is a substantial likelihood the individual is a carrier and a health threat to others. (PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

MCL 333.5207; MSA 14.15(5207) PC 110 (6/98)

PETITION AND EX PARTE ORDER FOR TRANSPORT AND/OR TEMPORARY DETENTION

7. There is an emergency which requires the protection of public health. IT IS ORDERED: 8. The individual be taken into protective custody by a health officer peace officer and transported to
Name of facility

community health department representative

local public ,

or to another appropriate emergency care or treatment facility, for observation, 9. The
Name of facility

examination,

testing,

diagnosis,

treatment,

and

temporary detention.

facility shall detain the individual

for no longer than 72 hours, excluding Saturdays, Sundays, and legal holidays, unless otherwise ordered by the court. 10. The person transporting the individual shall promptly notify the court of the facility where the individual has been received and temporarily detained. 11. A copy of this order shall be served upon the individual immediately upon apprehension or detention.

Date

Judge

Bar no.

CERTIFICATE OF SERVICE I certify that immediately upon apprehension/detention of the individual, I personally served on him/her a copy of the this petition and order.

Date

Signature

Title

NOTICE OF TIME OF TEMPORARY DETENTION TO THE CIRCUIT COURT: You are notified that the individual was detained at
Place and location

on
Date

at
Time

m.

Date

Signature

NOTE: This notice must be promptly filed with the circuit court.