Free Recommendaiton of Commitment Review Panel - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTY

CASE NO. RECOMMENDATION OF COMMITMENT REVIEW PANEL Original Continued Appeal

In the matter of The following named panel members have training and experience in the diagnosis and treatment of serious communicable diseases and infections:
Names of physicians

1. We have reviewed the record of the proceeding, including the petition or claim of appeal filed with the court, and any other information we considered relevant. 2. We interviewed the individual on
Date

.

3. We did not interview the individual because . an infectious agent. a serious communicable disease. a serious communicable infection.

4. The individual is a carrier of

,

5. The individual is a health threat to others because:

6. The individual requires the following treatment:

7. We recommend treatment in
Name of facility

for a period of
Number of days or months

for the following reasons:

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PC 108 (6/98)

RECOMMENDATION OF COMMITMENT REVIEW PANEL

MCL 333.5205(10); MSA 14.15(5205)(10), MCR 5.782

8. We recommend the following alternative(s) to commitment:

The reasons for this recommendation are:

9. We recommend continuation of the commitment as ordered on
Date

for the following reasons:

10. We recommend termination of the current commitment as ordered on
Date

for the following reasons:

I certify that I am a physician licensed in the state of Michigan. I declare that this report 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.

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

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