TO:COURTOFPROBATE,DISTRICTNO. PANELEVALUATION/PANELMEMBER[Name,address,and]respondent'scase:2.Therespondentisphysiologicallysexuallymature:PANELEVALUATION/STERILIZATIONOFADULTPC-773DATEAPPOINTEDTOPANELCONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com 3.Thereisnoevidenceofinfertility:4.Therespondenthasthecapabilityandareasonableopportunityforsexualactivity:5.The respondent is unable to understand reproduction or contraception, and there exists the likely permanence of that inability:6.The respondent's physical or emotional inability to care for a child:7.Theproponentsofthesterilizationareseekingsterilizationingoodfaith,andtheirprimaryconcernisforthebestinterestsoftherespondentratherthantheirownconvenienceortheconvenienceofthepublic:8.In the case of females, procreation would endanger the life or severely impair the health of the individual: NOTETOPANELMEMBER:Thefollowingisthestatutoryrequirementfortheevidenceconcerningtherespondent.C.G.S.24745a-695.Atanyhearinguponsuchapplication,thecourtshallreceiveevidenceconcerningtherespondent'sabilitytogiveinformedconsent.Suchevidenceshallinclude,butshallnotbelimitedto,swornreportsinwritingfromaninterdisciplinaryteamofatleastthreeimpartialpanelmembersappointedbythecourtfromapanelofphysicians,psychologists,educators,andsocialandresidentialworkerswhohavepersonallyobserved,examined,orworkedwithsuchrespondentatsometimeduringthetwelvemonthsprecedingsuchhearing.SuchappointmentsshallbemadeinaccordancewithregulationspromulgatedbytheProbateCourtAdministratorinaccordancewithsection45a-77.Thereasonablecompensationofsuchappointedpanelmembersshallbeestablishedbythecourt.Suchcompensation shallbechargedtotherespondentprovided,ifthecourtfindssuchrespondentisunabletopaysuchcompensation,itshallbepaidfromtheProbateCourtAdministrationFund.Eachsuchappointedpanelmembershallmakehisswornwrittenreportonaseparateformprovidedforthatpurposebythecourtandshallanswersuchquestionsasmaybesetforthontheformasfullyandcompletelyasreasonablypossible.Thereportsshallcontainspecificinformationregardingtherespondent'sabilitytogiveinformedconsentandshallindicatethespecificaspectsofinformedconsentwhichtherespondentlacks.Eachsuchappointedpanelmembershallstateupontheformsthereasonsforhisopinion.Suchrespondentorhiscounselshallhavetherighttopresentevidenceandcross-examinewitnesseswhotestifyatanyhearingon theapplication.Ifsuchrespondentorhiscounselnotifiesthecourtlessthanthreedaysbeforethehearingthathewishestocross-examinetheappointedpanelmembers,thecourtshallsuchmemberstoappear.notorder PANEL EVALUATION / STERILIZATION OF ADULTPC - 773 (Reverse) REV. 10/00Togivefurtherdetails,useSecondSheet,PC-180.[] Therepresentationscontainedhereinaremadeunderthepenaltiesoffalsestatement.Date:Panel Member.............................................................................Print Name: American LegalNet, Inc. www.FormsWorkFlow.com