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MA-3 Report of Law Enforcement Officer Initiating Protective Custody MA

Report of Law Enforcement Officer Initiating Protective Custody

State of Florida, County of ______________________, Florida

I,_____________________________________, am a law enforcement officer certified by the State of Florida. I

have good faith reason to believe that ______________________________________________ appears to meet

the following criteria for protective custody:

He/she

is substance abuse impaired and, because of such impairment:

Has lost the power of self-control with respect to substance use; and either

Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on

himself or herself or another; or

Is in need of substance abuse services and, by reason of substance abuse impairment, his or her judgment

has been so impaired that the person is incapable of appreciating his or her need for such services and of

making a rational decision in regard thereto; however, mere refusal to receive such services does not

constitute evidence of lack of judgment with respect to his or her need for such services.

Circumstances which support this opinion: _________________________________________________________

___________________________________________________________________________________________

______________________________________

___________________

____ am pm

Signature of Law Enforcement Officer

Date (mm/dd/yyyy)

Time

______________________________________________

___________________________________

Printed Name of Law Enforcement Officer

Full Name of Law Enforcement Agency

___________________________________________

________________________________________

Badge or ID Number

Law Enforcement Case Number

Transportation to Substance Abuse Provider

Location Found:

Taken To:

Family members or others present when person was taken into custody

Name

Address

Relationship

Phone Number

Next of Kin (if known)

Indicate personal knowledge by family members and others about the person’s condition

______________________________________________________________________________________________

FORM MA-3

By Authority of s. 397.677, Florida Statutes

MARCHMAN ACT

Marchman Act Handbook Page 259

Form Ma-3 - Report Of Law Enforcement Officer Initiating Protective Custody - State Of Florida

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