Free PC-773 - Connecticut

PANEL EVALUATION/ STERILIZATION OF ADULT PC-773 REV. 10/00

STATE OF CONNECTICUT
RECORDED(CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink.] DISTRICT NO.
DATE OF BIRTH OF RESPONDENT

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF Hereinafter referred to as the respondent. PANEL MEMBER [Name, address, and zip code]

PROFESSION OF PANEL MEMBER Physician, Conn. License No. Psychologist, Conn. License No. Educator Social Worker

DATE APPOINTED TO PANEL

Residential Worker

THE ABOVE-NAMED COURT-APPOINTED PANEL MEMBER REPRESENTS that he or she has personally observed, examined, or worked with the respondent during the twelve months preceding the following date(s): and that this report has been answered as fully and completely as is reasonably possible. THE PANEL MEMBER REPRESENTS that in his or her opinion: the respondent is able to give informed consent. the respondent is NOT able to give informed consent. THE PANEL MEMBER supports the above determination with the following specific information regarding: The respondent's ability to give informed consent:

Aspects of informed consent that the respondent lacks (if any):

Describe the respondent's physical condition.

Describe the respondent's mental condition.

[This section is to be completed if, in the opinion of the panel member, the respondent is NOT able to give informed consent, or if the respondent is under conservatorship or guardianship.] THE PANEL MEMBER REPRESENTS that in his or her opinion: all of the following "best interest" requirements HAVE been met with respect to the respondent, all of the following "best interest" requirements HAVE NOT been met with respect to the respondent, and gives full explanation of supporting evidence for each requirement below. C.G.S. §45a-690. 1. Less drastic alternative contraceptive methods have proved unworkable or inapplicable in the respondent's case:

2. The respondent is physiologically sexually mature:

[Continued on reverse side.] PANEL EVALUATION/STERILIZATION OF ADULT PC-773

RESET

3. There is no evidence of infertility:

4. The respondent has the capability and a reasonable opportunity for sexual activity:

5. The respondent is unable to understand reproduction or contraception, and there exists the likely permanence of that inability:

6. The respondent's physical or emotional inability to care for a child:

7. The proponents of the sterilization are seeking sterilization in good faith, and their primary concern is for the best interests of the respondent rather than their own convenience or the convenience of the public:

8. In the case of females, procreation would endanger the life or severely impair the health of the individual:

[To give further details, use Second Sheet, PC-180.] The representations contained herein are made under the penalties of false statement. Date: ............................................................................. Panel Member Print Name:

NOTE TO PANEL MEMBER: The following is the statutory requirement for the evidence concerning the respondent. C.G.S. §45a-695. At any hearing upon such application, the court shall receive evidence concerning the respondent's ability to give informed consent. Such evidence shall include, but shall not be limited to, sworn reports in writing from an interdisciplinary team of at least three impartial panel members appointed by the court from a panel of physicians, psychologists, educators, and social and residential workers who have personally observed, examined, or worked with such respondent at some time during the twelve months preceding such hearing. Such appointments shall be made in accordance with regulations promulgated by the Probate Court Administrator in accordance with section 45a-77. The reasonable compensation of such appointed panel members shall be established by the court. Such compensation shall be charged to the respondent provided, if the court finds such respondent is unable to pay such compensation, it shall be paid from the Probate Court Administration Fund. Each such appointed panel member shall make his sworn written report on a separate form provided for that purpose by the court and shall answer such questions as may be set forth on the form as fully and completely as reasonably possible. The reports shall contain specific information regarding the respondent's ability to give informed consent and shall indicate the specific aspects of informed consent which the respondent lacks. Each such appointed panel member shall state upon the forms the reasons for his opinion. Such respondent or his counsel shall have the right to present evidence and cross-examine witnesses who testify at any hearing on the application. If such respondent or his counsel notifies the court not less than three days before the hearing that he wishes to cross-examine the appointed panel members, the court shall order such members to appear. PANEL EVALUATION / STERILIZATION OF ADULT PC - 773 (Reverse) REV. 10/00 RESET