Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT COURT
COUNTY

PETITION FOR TREATMENT
OF INFECTIOUS DISEASE

CASE NO.

In the matter of

1. I,

Name (type or print)

and make this petition in respect to,

Name (type or print)

resides at

Address

and who is presently found at

Address or location

, am a

local health officer
State Community Health Department representative

       , who is

a minor
an adult    and who

City

State

Zip

.

   .

2. An  ex parte detention order was issued by this court on

       .

3. The individual is believed to be a carrier as to

Date

specify infectious agent or serious communicable disease or infection

a written warning notice was sent to the individual requiring

4. On

Date

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)

Do not write below this line - For court use only

PC 104   (6/98)   PETITION FOR TREATMENT OF INFECTIOUS DISEASE

MCL 333.5205; MSA 14.15(5205), MCR 5.782

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:

a warning notice.

9. The court order that the individual:

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. participate in the following designated programs:
 education.
b. undergo tests to verify his/her status as a carrier or for diagnosis.

 treatment.

 counseling.

c. appear at

Name of agency or facility

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

Place

f. other:

     for verification of status,

 .

10. The court appoint a commitment review panel and commit the individual to

Name of facility

.

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.

/s/
Attorney signature

Name (type or print)

Address

City, state, zip

Date
/s/
Petitioner signature

Name (type or print)

Address

Telephone no.

City, state, zip

Telephone no.