Supplement For Emergency Guardian Of Person

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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
Licensed Physician
Print Form
________________________________________________
Date of Report
17.1A - SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON

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