IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT STATE OF ALASKA, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, DIVISION OF PUBLIC HEALTH Petitioner, vs. Respondent. Petitioner Name: Petitioner Title: Petitioner Agency: 1. I am the petitioner named above. I am authorized to petition the court on behalf of the Alaska Department of Health and Social Services, Division of Public Health (the Department). I ask the court for an order to quarantine or isolate the respondent named above for 30 days. And I request a hearing on this petition within 48 hours as provided in AS 18.15.385(f). A medical officer from the State of Alaska determined that the respondent has or may have been exposed to this contagious disease: The respondent poses a significant risk to the public health. An emergency administrative order was issued pursuant to AS 18.15.385(e). Emergency action was necessary to prevent the transmission to others of a disease that poses a significant risk to the public health. 5. 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 determined that quarantine, isolation, or related procedures described below are necessary in the case of the respondent: Minor ) ) ) ) ) ) ) ) ) Case No. CI PETITION FOR QUARANTINE OR ISOLATION [AS 18.15.385(d)] 2. 3. 4. 6. Page 1 of 3 CIV-794 (12/15)(cs) PETITION FOR QUARANTINE/ISOLATION ORDER AS 18.15.385(d)-(h) American LegalNet, Inc. www.FormsWorkFlow.com 7. 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: 8. The respondent or the respondent's legal guardian: does not consent to quarantine or isolation; or cannot be reached to give consent to quarantine or isolation; or lacks the capacity to consent or object to quarantine or isolation because: 9. 10. The respondent is unable or unwilling to behave so as not to expose other people to infection. The respondent is: currently quarantined or in isolation at this location: not currently quarantined or in isolation. I request that the court order a peace officer to deliver the respondent to the premises described below for quarantine or isolation until a hearing is held. 11. The premises subject to quarantine or isolation are as follows: The respondent will be confined to home at this address: Instead of home, the respondent will be confined to the premises at: because the following exceptional circumstances prevent the respondent from being confined to home: Page 2 of 3 CIV-794 (12/15)(cs) PETITION FOR QUARANTINE/ISOLATION ORDER AS 18.15.385(d)-(h) American LegalNet, Inc. www.FormsWorkFlow.com 12. Quarantine or isolation should be required starting on this date and time: Date: Time: 13. When isolating or quarantining the respondent, the Department will adhere to the following conditions and standards: a. Isolation and quarantine will be by the least restrictive means necessary to prevent the spread of a contagious or possibly contagious disease that poses a significant risk to public health. Isolation and quarantine may include confinement to private homes or other private and public premises. Unless there are exceptional circumstances that would jeopardize public health, the respondent will be allowed to choose confinement in the respondent's home. If isolated, the respondent shall be confined separately from quarantined persons. The health status of the isolated or quarantined respondent will be monitored regularly to determine whether continued isolation or quarantine is required. If quarantined, and the respondent subsequently becomes infected or is reasonably believed to have become infected with a contagious or possibly contagious disease, the respondent shall promptly be removed to isolation. Any isolation and quarantine order will be immediately terminated when the respondent poses no substantial risk of transmitting a contagious or possibly contagious disease to other persons. The court will be promptly notified of the termination date and time. b. c. d. e. f. 14. This petition is accompanied by an affidavit signed by a state medical officer pursuant to AS 18.15.385(d)(2). Date Phone Fax Email Signature of Petitioner Print Name Address Line 1 Address Line 2 Page 3 of 3 CIV-794 (12/15)(cs) PETITION FOR QUARANTINE/ISOLATION ORDER AS 18.15.385(d)-(h) American LegalNet, Inc. www.FormsWorkFlow.com