PC-G-17.1B (Rev. 12-2000) PROBATE COURT OF FRANKLIN COUNTY, OHIO JUDGE A. BELSKIS, JUDGE LAWRENCE ALAN S. ACKER IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. SUPPLEMENT FOR EMERGENCY GUARDIAN [R.C. 2111.02(B)(3)] 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 17.1A, must be checked. A. Does the patient 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 or the estate: E. Ability of the alleged Incompetent to receive notice and give informed 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 any be supplemented by attachments. Date and Time of Evaluation Date of Report FRANKLIN COUNTY FORM 17.1B - Evaluating Physician/Clinical Psychologist SUPPLEMENT FOR EMERGENCY GUARDIAN American LegalNet, Inc. www.FormsWorkFlow.com