Instructions to the physician preparing the report on clinical evaluation 

  This form may be filed in a court case to appoint a guardian or conservator for 
the patient, and it may be treated as evidence of the patient’s incapacity and 
need for protection. 

  You may not be able to answer every question within the scope of your 

evaluation. As well as you are able, answer the questions for which you have 
information based on your personal observations, based on statements by the 
patient, or based on a source on which you commonly rely in your professional 
capacity. 

  After completing the evaluation, date and sign the form and return it to the person 
who requested the examination and evaluation. That person will file the report 
with the court and, as needed, serve the report on the respondent. When filed 
with the court, this is a private record and available only to the court and those 
involved in the case. 

2012.09 

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Instructions to the physician preparing the report on clinical evaluation

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Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

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About This Form:

• Sourced from legacy.utcourts.gov (2023-03)
• Page(s): 1
• Fields(s): 0
• Average fields per page: 0
• Reading Level: Grade 15
• LIST Grouping(s): CO-00-00-00-00, CO-07-00-00-00.

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