Approved, SCAO STATE OF MICHIGAN CASE NO. PETITION AND EX PARTE ORDER FOR JUDICIAL CIRCUIT COURT COUNTY TRANSPORT AND/OR TEMPORARY DETENTION In the matter of PETITION local health officer 1. I, , am a State Community Health Department representative and make Name (type or print) a minor this affidavit in respect to, , who is an adult and who resides in Name (type or print) County at Address City and who is presently found at . State Zip Address, location, or facility 2. An emergency exists and there is reasonable cause to believe that the individual is a carrier and a health threat to others for the reasons stated in the attached affidavit. I REQUEST: 3. the individual be taken into custody and transported to , Name of facility an emergency care or treatment facility, for observation. examination. testing. diagnosis. treatment. 4. the individual be detained temporarily at the facility and a hearing be held within the next 72 hours to determine whether temporary detention should continue up to five days, and longer if a petition for treatment of an infectious disease is filed within that five days. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature Address Name (type or print) City, state, zip Telephone no. ORDER THE COURT FINDS: 5. An affidavit has been filed in compliance with Section 5207 of the Public Health Code. 6. Reasonable cause exists to believe that there is a substantial likelihood the individual is a carrier and a health threat to others. (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 333.5207; MSA 14.15(5207)PC 110 (6/98) PETITION AND EX PARTE ORDER FOR TRANSPORT AND/OR TEMPORARY DETENTION >>>> 27. There is an emergency which requires the protection of public health. IT IS ORDERED: 8. The individual be taken into protective custody by a community health department representative local public health officer peace officer and transported to , Name of facility or to another appropriate emergency care or treatment facility, for observation, examination, testing, diagnosis, treatment, and temporary detention. 9. The facility shall detain the individual Name of facility for no longer than 72 hours, excluding Saturdays, Sundays, and legal holidays, unless otherwise ordered by the court. 10.The person transporting the individual shall promptly notify the court of the facility where the individual has been received and temporarily detained. 11. A copy of this order shall be served upon the individual immediately upon apprehension or detention. Date Judge Bar no. CERTIFICATE OF SERVICE I certify that immediately upon apprehension/detention of the individual, I personally served on him/her a copy of the this petition and order. Date Signature Title NOTICE OF TIME OF TEMPORARY DETENTION TO THE CIRCUIT COURT: You are notified that the individual was detained at Place and location on Date at Time m. Date Signature NOTE: This notice must be promptly filed with the circuit court.