Approved, SCAO
STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTY
AFFIDAVIT TO ACCOMPANY PETITION FOR TRANSPORT AND/OR TEMPORARY DETENTION
CASE NO.
In the matter of
1. I believe
Name (type or print)
to be a carrier of because of the following facts:
specify infectious agent or serious communicable disease or infection
2. I believe the individual is a health threat to others because of the following facts:
3. The individual requires the following services at an emergency care or treatment facility:
4. An emergency order is necessary because of the following facts:
Date Affiant's signature Name (type or print) Address City, state, zip Telephone no.
Subscribed and sworn to before me on
Date
, Signature:
County, Michigan.
My commission expires:
Date
Notary public
Do not write below this line - For court use only
MCL 333.5207(1),(2); MSA 14.15(5207)(1), (2), MCR 5.782 PC 109 (6/98)
AFFIDAVIT TO ACCOMPANY PETITION FOR TRANSPORT AND/OR TEMPORARY DETENTION