Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT COURT ORDER APPOINTING COUNTY COMMITMENT REVIEW PANEL Original Modified In the matter of 1. Date of Hearing: Judge: Bar no. 2. The court received a petition for treatment of infectious disease requesting that the individual be committed to . Name of facility 3. The court received a motion from the above named individual requesting that Dr. , a physician, be appointed to the commitment review panel previously appointed by the court. IT IS ORDERED: 4. The following physicians are appointed to the commitment review panel. Name Address City State Zip Name Address City State Zip Name Address City State Zip 5. Dr. is discharged from the panel and the following physician is appointed to the commitment review panel as requested by the individual. Name Address City State Zip 6. The commitment review panel shall a. review the need for commitment of the individual to a health facility. b. review the record of the proceeding. c. interview the individual, or document the reasons why the individual was not interviewed. d. recommend either commitment or an alternative or alternatives to commitment and document the reasons for the recommendation. e. make its recommendation to the court in writing before . Date of hearing Judge Do not write below this line - For court use only PC 107 (9/98) ORDER APPOINTING COMMITMENT REVIEW PANEL MCL 333.5205(8); MSA 14.15(5205)(8), MCR 5.782