Fill and Sign the Petition for Treatment Form

local health officer 1. I, , am a State Community Health Department representative a minor and make this petition in respect to, , who is an adult and who resides at and who is presently found at. 2. An ex parte detention order was issued by this court on . 3. The individual is believed to be a carrier as to . 4. On a written warning notice was sent to the individual requiring him/her to cooperate with the Community Health Department or local health department to prevent or control transmission of which is a serious communicable disease or infection. The individual has failed or refused to comply with the warning notice. 5. The individual is a health threat to others because of the demonstrated inability or unwillingness to conduct himself or herself in such a manner as to not place others at risk of exposure to the serious communicable disease or infection. The health threat to others is shown by: a. Behavior by the carrier that has been demonstrated epidemiologically to transmit, or that evidences a careless disregard for transmission of, a serious communicable disease or infection to others. b. A substantial likelihood that the carrier will transmit a serious communicable disease or infection to others, as evidenced by the carrier's past behavior or statements made by the carrier that are credible indicators of the carrier's intention to do so. c. Affirmative misrepresentation by the carrier of his or her status as a carrier before engaging in behavior that has been demonstrated epidemiologically to transmit the serious communicable disease or infection. d. Other: (explain) (PLEASE SEE OTHER SIDE) Name (type or print) AddressCity State Zip Address or location Date PC 104 (6/98) PETITION FOR TREATMENT OF INFECTIOUS DISEASE In the matter of STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTYCASE NO. PETITION FOR TREATMENT OF INFECTIOUS DISEASE MCL 333.5205; MSA 14.15(5205), MCR 5.782 Approved, SCAO specify infectious agent or serious communicable disease or infection Date Do not write below this line - For court use only Name (type or print) 6. This conclusion is based upon: a. My personal observation of the individual doing the following acts and saying the following things: b. Conduct and statements I have been informed that others have seen or heard: 7. An emergency order is not sought and before issuing the warning notice, the following steps were taken to alleviate the health threat to others: I REQUEST: 8. A hearing be held and the court find that the individual is a health threat to others and/or has failed or refused to comply with a warning notice. 9. The court order that the individual: a. participate in the following designated programs: education. treatment. counseling. b. undergo tests to verify his/her status as a carrier or for diagnosis. c. appear at for verification of status, testing, or other purposes consistent with monitoring. d. cease and desist conduct that constitutes a health threat to others. e. live part-time or full-time in a supervised setting at . f. other: 10. The court appoint a commitment review panel and commit the individual to . I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Name (type or print) Attorney signature City, state, zip Address Telephone no. Telephone no. City, state, zip Address Name (type or print)Petitioner signature Date Name of agency or facility Name of facility Place