Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT COURT RECOMMENDATION OF COUNTY COMMITMENT REVIEW PANEL Original Continued Appeal In the matter of The following named panel members have training and experience in the diagnosis and treatment of serious communicable diseases and infections: Names of physicians 1. We have reviewed the record of the proceeding, including the petition or claim of appeal filed with the court, and any other information we considered relevant. 2. We interviewed the individual on . Date 3. We did not interview the individual because . an infectious agent. 4. The individual is a carrier of , a serious communicable disease. a serious communicable infection. 5. The individual is a health threat to others because: 6. The individual requires the following treatment: 7. We recommend treatment in for a period of Name of facility Number of days or months for the following reasons: (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only PC 108 (6/98) RECOMMENDATION OF COMMITMENT REVIEW PANEL MCL 333.5205(10); MSA 14.15(5205)(10), MCR 5.782>>>> 2 8. We recommend the following alternative(s) to commitment: The reasons for this recommendation are: 9. We recommend continuation of the commitment as ordered on Date for the following reasons: 10.We recommend termination of the current commitment as ordered on Date for the following reasons: I certify that I am a physician licensed in the state of Michigan. I declare that this report has been examined by me and that its contentsare true to the best of my information, knowledge, and belief. Date Date Signature Signature Name (type or print) Name (type or print) Address Address City, state, zip Telephone no. City, state, zip Telephone no.Date Signature Name (type or print) Address City, state, zip Telephone no.