Docket No. ROGERS MONITOR SUPPLEMENTAL REPORT TO THE GUARDIAN'S CARE PLAN/REPORT Commonwealth of Massachusetts The Trial Court Probate and Family Court Division In the Interests of: Middle Name First Name Last Name Incapacitated Person THIS FORM MAY ONLY BE USED BY A ROGERS MONITOR WHO IS ALSO THE GUARDIAN OF THE INCAPACITATED PERSON. 1. Please list the date on which you last reviewed the Incapacitated Person's medical records and current treatment plan, including the treating physician's treatment reports. Date: 2. The Incapacitated Person's current living circumstances are detailed in the attached Guardian's Care Plan/Report. 3. Were the physician's treatment reports complete and consistent with the Incapacitated Person's medical records? Yes No If No, please explain: 4. Please list the date when you last communicated with the treating physician. Date: 5. If you were unable to meet or speak with the treating physician in the last 6 months, please detail the attempts you made to contact the treating physician during that time period. 6. If you were unable to speak with the treating physician, did you review the physician's progress notes? Yes No 7. Please list other associated staff members with whom you have discussed the Incapacitated Person's current status and treatment needs. Staff Member's Name MPC 824 (5/30/11) Title Date(s) of Discussion Length in Time of Discussion page 1 of American LegalNet, Inc. www.FormsWorkFlow.com 2 8. Please describe the substance of the communications you had with the treating physician or associated staff members or information you gathered from reviewing the physician's progress notes regarding the Incapacitated Person's present status and the treatment needs with regard to the administration of antipsychotic medication. 9. What is the authorizing date and expiration date of the Court's last Order authorizing the administration of antipsychotic medication? Date allowed: Expiration Date: 10. Please list the current antipsychotic medications being administered to the Incapacitated Person and indicate any such antipsychotic medication being administered which is not authorized by the Court's last order as a primary or alternate medication: Medication Dosage Range Date Treatment Began Authorized by Court's Last Order? Yes No Yes No Yes No 11. Are the antipsychotic medications being administered consistent with the Incapacitated Person's medical needs? Yes No If No, please describe how they are not: 12. Since the Court's last order authorizing the administration of antipsychotic medication, has there been any change in the Incapacitated Person's capacity to make medical decisions, including treatment with antipsychotic medication? No Yes If Yes, please describe the change: Date: SIGNATURE OF ROGERS MONITOR (Print Name) SIGNATURE OF CO-ROGERS MONITOR (if applicable) (Print Name) MPC 824 (5/30/11) page 2 of American LegalNet, Inc. www.FormsWorkFlow.com 2