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PETITION 2. An emergency exists and there is reasonable cause to believe that the in\ dividual is a carrier and a health threat to others f or the reasons stated in the attached affidavit. I REQUEST : 3. The individual be taken into custody and transported to , an emergency care or treatment facility, for observation. examination. testing. diagnosis. treatment. 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 5 days, and longer if a petit\ ion for treatment of an infectious disease is filed wit hin that 5 days. I declare under the penalties of perjury that this petition has been exa\ mined by me and that its contents are true to the best of my information, knowledge, and belief. ORDER THE COURT FINDS: 5. An affidavit has been filed in compliance with MCL 333.5207. 6. Reasonable cause exists to believe that there is a substantial likelihoo\ d the individual is a carrier and a health threat to others. (PLEASE SEE OTHER SIDE) local health officer 1. I, , am a State Community Health Department representative and make a minor this affidavit in respect to , who is an adult and who resides in County at and who is presently found at . Name (type or print) Address City State Zip Address, location, or facility Name of facility Date Signature Name (type or print) City, state, zip Address Telephone no. In the matter of Approved, SCAO STATE OF MICHIGANJUDICIAL CIRCUIT COURT COUNTY CASE NO. PETITION AND EX PARTE ORDER FOR TRANSPORT AND/OR TEMPORARY DETENTION Do not write below this line - For court use only PC 110 (9/09) PETITION AND EX PARTE ORDER FOR TRANSPORT AND/OR TEMPORARY DETENTION MCL 333.5207 Name (type or print) 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 community health department representative local publichealth officer peace officer and transported to , or to another appropriate emergency care or treatment facility, for observation, examination, testing, diagnosis,treatment, and temporary detention. 9 . The facility shall detain the individual for no longer than 72 hours, excluding Saturdays, Sundays, and legal hol\ idays, unless otherwise ordered by the court. 10. The person transporting the individual shall promptly notify the court o\ f the facility where the individual has been receive d and temporarily detained. 11. A copy of this order shall be served on the individual immediately upon \ apprehension or detention. CERTIFICATE OF SERVICE I certify that immediately upon apprehension/detention of the individual\ , I personally served the individual a copy of this petition and order. NOTICE OF TIME OF TEMPORARY DETENTION TO THE CIRCUIT COURT: You are notified that the individual was detained at on at . NOTE: This notice must be promptly filed with the circuit court. Name of facility Date Judge Date Signature Title Date Place and location Date Signature Bar no. Name of facility Time