IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT STATE OF ALASKA, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, DIVISION OF PUBLIC HEALTH Petitioner, vs. Respondent. Minor ) ) ) ) ) ) ) ) ) Case No. CI APPLICATION FOR EX PARTE ORDER FOR TESTING, EXAMINATION, OR SCREENING [AS 18.15.375(c)-(e)] Applicant Name: Applicant Title: Applicant Agency: 1. I am the applicant named above. I am authorized to make this application on behalf of the Alaska Department of Health and Social Services, Division of Public Health (the Department). A medical officer from the State of Alaska determined that the respondent has or may have been exposed to this contagious disease: , and determined that this condition poses a significant risk to the public health. The following facts support these determinations: 2. 3. This condition may be avoided, cured, alleviated, or made less contagious through safe and effective treatment, modifications in individual behavior, or public health intervention. A medical officer from the State of Alaska issued an administrative order requiring the respondent to undergo testing, examination, or screening. The administrative order was personally served on the respondent pursuant to AS 18.15.375(c)(2). The respondent is under age 18. Parent's name and address: Name: Address: The respondent has a legal guardian. Legal guardian's name and address: Name: Address: 4. 5. Page 1 of 2 CIV-790 (12/15)(cs) APPLICATION FOR EX PARTE ORDER AS 18.15.375(c)-(e) American LegalNet, Inc. www.FormsWorkFlow.com 6. The respondent or the respondent's legal guardian: objects to the administrative order of the state medical officer; or cannot be reached to give consent to the administrative order; or lacks the capacity to consent or object to the administrative order because: 7. The respondent is currently: detained under an order of isolation or quarantine, and has been detained since (insert date) . not detained. If a hearing is requested (on the ex parte application), I request that the court order a peace officer to take the respondent into protective custody until a hearing is held. 8. I believe the respondent is currently located at: 9. I request that the court issue an ex parte order for testing, examination or screening the respondent for the condition listed above. I say on oath or affirm that I read this document and believe all statements made in the document are true. Signature of Applicant Phone Fax Email Print Name Address Line 1 Address Line 2 , Alaska Subscribed and sworn to or affirmed before me at on ___________________. (date) (SEAL) I certify that on , a copy of this application was given to: Respondent Respondent's Attorney GAL By Clerk: Page 2 of 2 CIV-790 (12/15)(cs) APPLICATION FOR EX PARTE ORDER Clerk of Court, Notary Public or other person Authorized to administer oaths. My Commission Expires: AS 18.15.375(c)-(e) American LegalNet, Inc. www.FormsWorkFlow.com