PROBATE COURT OF __________________ COUNTY, OHIO 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.C, page 1 of the Statement of Expert Evaluation, Form 17.1 must be checked. A. Does this 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 given 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 OF PERSON American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com