Free PC-904 - Connecticut

PETITION/ JUDICIAL ORDER ENFORCING EXAMINATION OF RESPONDENT FOR TUBERCULOSIS PC-904 REV. 3/03

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.]

RECORDED (CONFIDENTIAL VOLUME):

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF[Name, address, and zip code]

DISTRICT NO. PETITIONER[Name, address, zip code, and telephone number]

Director of Health for the Town, City, or Borough of: Hereinafter referred to as the respondent. I, the undersigned petitioner, represent that: 1. I am the duly appointed Director of Health for the Town, City, or Borough as indicated above. 2. The respondent resides within my jurisdiction, AND, in my professional judgment, has active tuberculosis OR is suspected of having active tuberculosis. [ Recite factual basis for judgment. ]

3. The following are the efforts that have been made to educate the respondent about the need to be examined for active tuberculosis:

4. On

, I issued a written warning to the respondent to be examined by a physician for tuberculosis.

5. Notwithstanding the foregoing, the respondent is unable or unwilling to be examined voluntarily. 6. In my further professional judgment, the order requested below is necessary and is the least restrictive alternative available to protect the public health. 7. I have NOT issued an emergency commitment order to date, but in my further professional judgment: of [Name of facility] is a medically appropriate facility or setting at which to conduct such examination.

[Address]

WHEREFORE, the petitioner respectfully requests the Court to enter an order under C.G.S.§ 19a-265 (e) and (k) enforcing the examination of the respondent for tuberculosis at the foregoing facility or setting. Dated at: ,Connecticut, on [Month, Day, Year]

The representations contained herein are made under the penalties of false statement. .................................................................... Petitioner:

PETITION/ JUDICIAL ORDER ENFORCING EXAMINATION OF RESPONDENT FOR TUBERCULOSIS PC-904 RESET