Approved, SCAO STATE OF MICHIGAN CASE NO. PETITION FOR CONTINUED COMMITMENT JUDICIAL CIRCUIT COURT FOR TREATMENT OF INFECTIOUS DISEASE COUNTY AND ORDER TO RECONVENE COMMITMENT REVIEW PANEL In the matter of 1. I am director of the . Name of facility 2. The above named individual was committed to this facility for a period of by court order Number of days or months dated . 3. The individual requires continued commitment for the following reasons: I REQUEST that the court issue an order to continue commitment of the individual at the above named facility for a period of and under the conditions set by the court. Number of days or months 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 of director Address Name (type or print) City, state, zip Telephone no. ORDER 1. Date of Hearing: Judge: IT IS ORDERED: 2. The previously appointed commitment review panel consisting of , , and shall reconvene and report to the court in writing within 14 days of the filing of this petition. 3. The panel shall do the following: a. Review the petition and any other information considered relevant by the commitment review panel. b. Interview the individual, or document the reasons why the individual was not interviewed. c. Recommend to the circuit court either termination or continuation of the commitment and document reasons for the recommendation. Date Judge Do not write below this line - For court use only PC 115 (6/98) PETITION FOR CONTINUED COMMITMENT FOR TREATMENT OF INFECTIOUS DISEASE AND ORDER TO RECONVENE COMMITMENT REVIEW PANEL MCL 333.5205(4)(h); MSA 14.15(5205(6)(h), MCR 5.782