Free Microsoft Word - Guardianship Series 15-17.7.DOC - Ohio

PROBATE COURT OF _____________ COUNTY, OHIO
IN THE MATER 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 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 ________________________________________________ Date of Report
17.1A - SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON

________________________________________ Licensed Physician