PETITION/JUDICIAL ORDER CONTINUING A PRIOR EMERGENCY COMMITMENT FOR TREATMENT OF TUBERCULOSIS PC-903 REV. 3/03 TO: COURT OF PROBATE, STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. Use with Decree, PC-962.] RECORDED (CONFIDENTIAL VOLUME): DISTRICT NO. PETITIONER[Name, address, zip code, and telephone number] IN THE MATTER OF[Name, address, and zip code] 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 OR presents a substantial likelihood of having active tuberculosis, AND poses a substantial and imminent likelihood of transmitting tuberculosis to others because of inadequate separation from others. [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 take required contagion precautions to avoid exposing others and of 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 behave so as not to expose others to risk of infection from tuberculosis and has expressed or demonstrated an unwillingness to adhere to the prescribed course of treatment that would render him or her non-infectious. [Recite factual basis for this statement.] 6. In my further professional judgment, commitment of the respondent for the purpose of treatment of this active tuberculosis is necessary AND is the least restrictive alternative available to protect the public health. 7. I have issued an emergency order under which the respondent has already been committed to: of [Name of facility] [Address] which, in my opinion, is a medically appropriate facility or setting to complete the necessary treatment, but this order will expire on: WHEREFORE, the petitioner respectfully requests the Court to enter a judicial commitment order under C.G.S§ 19a-265(f) authorizing the respondent's CONTINUED 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] The representations contained herein are made under the penalties of false statement. ................................................................................. Petitioner: PETITION/ JUDICIAL ORDER CONTINUING A PRIOR EMERGENCY COMMITMENT FOR TREATMENT OF TUBERCULOSIS PC-903 American LegalNet, Inc. www.FormsWorkFlow.com