PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge IN THE MATTER OF THE GUARDIANSHIP OF ___________________________________ CASE NUMBER ______________________________________ SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON [ R.C. 2111.49] This Supplement must be completed when there is a request for Emergency Guardianship. The following questions must be answered with specificity and item 1.C, page 1 of the Statement of Expert Evaluation, Form 17.1 must be checked. A. Does the individual have a durable health care power of attorney? _______ If yes, why is it not being honored? _________________________________________________________________________________________________ _________________________________________________________________________________________________ B. Exact nature of emergency: ____________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ C. Length of time emergency has existed, and why? ___________________________________________________ _________________________________________________________________________________________________ D. Specific action required to prevent significant injury to the person: ______________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ E. Ability of the alleged Incompetent to receive notice and give consent: ___________________________________ _________________________________________________________________________________________________ F. Medical prognosis in detail if immediate action, within 24 hours, is not taken: _____________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ G. Additional statements regarding condition, family, support services, etc.: _________________________________ _________________________________________________________________________________________________ note: Any above answers may be supplemented by attachments __________________________________ _______________________________ Date and Time of Evaluation Licensed Physician __________________________________ Date of Report 17.1A - SUPPLEMENT FOR EMERGENCY GUARDIAN OR PERSON 06/06 American LegalNet, Inc. www.FormsWorkflow.com