PETITION/ JUDICIAL COMMITMENT FOR THE TREATMENT OF TUBERCULOSIS [NO PRIOR EMERGENCY ORDER ISSUED] PC-902 REV. 3/03 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] [Use with Decree, PC-961.] RECORDED (CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF [Name, address where residing, and zip code.] DISTRICT NO. PETITIONER [Name, address, zip code, and telephone number] Director of Health for the Town, City, or Borough of: Hereinafter referred to as the respondent. I, the undersigned petitioner, represent that: 1. I am the duly appointed Director of Health for the Town, City, or Borough indicated above. 2. The respondent resides within my jurisdiction AND, in my professional judgment, has active tuberculosis. [Recite factual basis for judgment.] 3. The following are the efforts that have been made to educate and counsel the respondent about the need to complete the appropriate prescribed course of treatment: 4. The following is a description of the enablers and incentives that have been offered to the respondent to facilitate the completion of such treatment: 5. Notwithstanding the foregoing, the respondent is unable or unwilling to adhere to an appropriate prescribed course of treatment for tuberculosis and has a demonstrated pattern of persistent nonadherence to treatment for tuberculosis: [Recite factual basis for statement.]: 6. In my further professional judgment, commitment of the respondent for the purpose of treatment of this active tuberculosis is necessary to prevent the development of drug-resistant organisms, AND such commitment is the least restrictive alternative available to protect the public health in that other less restrictive alternatives to encourage the respondent's adherence to the prescribed course of treatment for tuberculosis have failed. 7. I have NOT issued an emergency commitment order to date, but in my further professional judgment: of [Name of facility] is a medically appropriate facility or setting to achieve the objectives of this petition. WHEREFORE, the petitioner respectfully requests the Court to enter a judicial commitment order under C.G.S. §19a-265 (c)(5) and (g) authorizing respondent's removal to and detention in the foregoing facility or setting for the purpose of facilitating completion of a prescribed course of treatment for tuberculosis. Dated at: ,Connecticut, on [Month, Day, Year] [Address] The representations contained herein are made under the penalties of false statement. ............................................................................ Petitioner: PETITION/JUDICIAL COMMITMENT FOR TREATMENT OF TUBERCULOSIS [NO PRIOR EMERGENCY ORDER ISSUED] PC-902 American LegalNet, Inc. www.FormsWorkFlow.com