Fill and Sign the 5515 Transfer of an Individual under a Protective Placement Form

GN -4340, 04/08 Notice of Transfer of Protective Placement §55.15(5), W isconsin Statute This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Notice of Transfer of Protective Placement Date of Birth Case No. 1. The placement of the individual under protective placement is being transferred by : guardian . county department or agency with which it contracts . the Wisconsin D epartment of Health Services . protective placement facility . 2. This transfer is being made: between protective placement units. between protective placement facilities. from a protective placement unit to a medical facility. This is not a tra nsfer to any facility for which commitment procedures are required under Chapter 51, Wisconsin Statutes. 3. NON -EMERGENCY TRANSFER. This Notice of T ransfer is being provided for a non -emergency transfer 10 days prior to the transfer to the court and to each of the persons and entities specified above who did not initiate the transfer. The guardian will provide written consent prior to the transfer. The county department will provide written consent prior to the transfer if this transfer is to a facility that is more costly to the county.  The individual under a protective placement, the individual’s attorney, if any, or other interested person has the right to petition the c ourt for a hearing on the transfer. 4. EMERGENCY TRANSFER. An emergency has made it impossible to provide prior notice or obtain prior written consent of the guardian. This notice of transfer is being provided for an emergency transfer immediately upon transfer to each of the persons and entities specified above who did not initiate the transfer, and to the court that ordered the protective placement within a reasonable time, not to exceed 48 hours from the time of transfer.  The individual under a protective placement, the individual’s guardian, the individual’s attorney, if any, or any other interested person has the right to file a petition with the court objecting to the emergency transfer. 5. This transfer will occur or has occurred at [Time] a.m. p.m. on [Date] , 20 . TRANSFER FROM : (Placement unit Name, address, tele phone number) TRANSFER TO : (Placement unit Name, address, telephone number) DISTRIBUTION: 1. Court 2. Guardian 3. County department or agency with which it contracts 4. Wisconsin Dept. of Health Services 5. Protective P lacement facility Person or Entity Representative initiating transfer Name Printed or Typed Date