Fill and Sign the State of Michigan Case No Judicial Circuit Court Order Form

The following named panel members have training and experience in the diagnosis and treatment of serious communicable diseases and infections: 1. We have reviewed the record of the proceeding, including the petition or claim of appeal filed with the court, and any other information we considered relevant. 2. We interviewed the individual on . 3. We did not interview the individual because . an infectious agent. 4. The individual is a carrier of , a serious communicable disease. a serious communicable infection. 5. The individual is a health threat to others because: 6. The individual requires the following treatment: 7. We recommend treatment in for a period of for the following reasons: (PLEASE SEE OTHER SIDE) Number of days or months Name of facility RECOMMENDATION OF COMMITMENT REVIEW PANEL Original Continued Appeal PC 108 (6/98) RECOMMENDATION OF COMMITMENT REVIEW PANEL In the matter of Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTYCASE NO. Do not write below this line - For court use only MCL 333.5205(10); MSA 14.15(5205)(10), MCR 5.782 Names of physicians Date 8. We recommend the following alternative(s) to commitment: The reasons for this recommendation are: 9. We recommend continuation of the commitment as ordered on for the following reasons: 10. We recommend termination of the current commitment as ordered on for the following reasons: I certify that I am a physician licensed in the state of Michigan. I declare that this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature Name (type or print) Address City, state, zipTelephone no. Date Signature Name (type or print) Address City, state, zipTelephone no. Date Signature Name (type or print) Address City, state, zipTelephone no. Date Date