Supplement For Emergency Guardian Of Person {17.1A}

FORM MUST BE TYPEWRITTEN OR CAN BE FILLED IN ON-LINE USING THE FORM AT THE COURT'S WEBSITE P R O B A TE C O U R T O F B U TLER C O U N TY , O H IO IN THE MATTER OF GUARDIANSHIP OF CASE NO. SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON [R.C. 2111.49] This Supplem ent m ust be com pleted when there is a request for Em ergency Guardianship. The following questions m ust be answered with specificity and item 1.C, page 1 of the Statem ent of Expert Evaluation, Form 17.1 m ust 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 em ergency: C. Length of tim e em ergency has existed, and why? D. Specific action required to prevent significant injury to the person: E. Ab ility of th e alleg ed Inc o m p ete nt to receiv e no tice and giv e co nse nt: F. M edical prognosis in detail if im m ediate action, within 24 hours, is not taken: G. Additional statem ents regarding condition, fam ily, support services, etc: Note: Any above answers m ay be supplem ented by attachm ents. Date and Time of Evaluation Signature - Licensed Physician Date of Report FORM 17.1A - SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON 06/2006 American LegalNet, Inc. www.FormsWorkflow.com