Probate Court of Lake County, Ohio Mark J. Bartolotta, Judge In the matter of the guardianship of_______________________________ Case No. _____________ 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., 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 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 ____________________________ Date of Report ________________________________ Licensed Physician American LegalNet, Inc. www.FormsWorkFlow.com