Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT COURT
COUNTY

In the matter of

PETITION AND EX PARTE ORDER FOR
TRANSPORT AND/OR
TEMPORARY DETENTION

CASE NO.

PETITION

 local health officer

1. I,

Name (type or print)

this affidavit in respect to

   , am a

   State Community Health Department representative    and make

           a minor

     , who is       an adult  and who resides in

Name (type or print)

         County at

Address

City

State

          Zip

Address, location, or facility

            and who is presently found at

2. An emergency exists and there is reasonable cause to believe that the individual is a carrier and a health threat to others for

the reasons stated in the attached affidavit.

I REQUEST:

3. The individual be taken into custody and transported to

Name of facility

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 petition for treatment of an infectious disease is filed within
 that 5 days.

I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my
information, knowledge, and belief.

    .

    ,

Telephone no.

Date

Signature

Name (type or print)

THE COURT FINDS:

Address

City, state, zip

ORDER

5. An affidavit has been filed in compliance with MCL 333.5207.

6. Reasonable cause exists to believe that there is a substantial likelihood the individual is a carrier and a health threat to others.

(PLEASE SEE OTHER SIDE)

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

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 public

health officer

peace officer

and transported to

Name of facility

or to another appropriate emergency care or treatment facility, for

    ,

observation,

    examination,

testing,

diagnosis,

treatment,    and

temporary detention.

9. The

Name of facility

     facility shall detain the individual

for no longer than 72 hours, excluding Saturdays, Sundays, and legal holidays, unless otherwise ordered by the court.

10. The person transporting the individual shall promptly notify the court of the facility where the individual has been received

and temporarily detained.

11. A copy of this order shall be served on the individual immediately upon apprehension or detention.

Judge

Bar no.

I certify that immediately upon apprehension/detention of the individual, I personally served the individual a copy of  this petition and
order.

CERTIFICATE OF SERVICE

Date

Date

on

Date

Date

NOTICE OF TIME OF TEMPORARY DETENTION

TO THE CIRCUIT COURT:

You are notified that the individual was detained at

Place and location

at

Time

  .

NOTE:  This notice must be promptly filed with the circuit court.

Signature

Title

Signature