Suffolk [or the superior court county where defendant lives]
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- BOARD OF HEALTH OF THE CITY ) OR TOWN OF [ _______________________]
- PHYSICIAN’S, OTHER HEALTH CARE PROVIDER’S, OR HEALTH OFFICIAL’S AFFIDAVIT OF PATIENT’S UNWILLINGNESS TO REMAIN ISOLATED AT HOME
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COMMONWEALTH OF MASSACHUSETTS SUFFOLK [OR THE SUPERIOR COURT COUNTY WHERE DEFENDANT LIVES] C.A. No. __________ ____________________________________________ ) COMMONWEALTH OF MASSACHUSETTS, BY ) AND THROUGH ____________________, ) COMMISSIONER OF PUBLIC HEALTH, and ) )
) ) Plaintiffs ) ) v. ) ) _____________________________ ) NAME OF INDIVIDUAL ) WHOSE ISOLATION IS SOUGHT ) ) Defendant (Patient) ) ) PHYSICIAN’S, OTHER HEALTH CARE PROVIDER’S, OR HEALTH OFFICIAL’S AFFIDAVIT OF PATIENT’S UNWILLINGNESS TO REMAIN ISOLATED AT HOME I, _______________________________, the undersigned, a physician or health care provider as defined in G.L. c. 111, § 1, and 105 CMR 300.020, or official of a local board of health or health department as created pursuant to G.L. c. 111, § 26A, et seq., in the Commonwealth of Massachusetts, or an official of the Massachusetts Department of Public Health, first being duly sworn, depose and say as follows: 1. I am a resident of ___________ County. I am over the age of twenty-one years, and I am otherwise legally competent to make this Affidavit.
Directory: eohhs -> docs -> dph -> disease-reporting disease-reporting -> Guide to Surveillance, Reporting and Control Massachusetts Department of Public Health, Bureau of Communicable Disease Control disease-reporting -> Guide to Surveillance, Reporting and Control Massachusetts Department of Public Health, Bureau of Communicable Disease Control dph -> Health of Massachusetts disease-reporting -> Guide to Surveillance, Reporting and Control Massachusetts Department of Public Health, Bureau of Communicable Disease Control dph -> - dph -> Indoor air quality assessment disease-reporting -> Guide to Surveillance, Reporting and Control Massachusetts Department of Public Health, Bureau of Communicable Disease Control disease-reporting -> Guide to Surveillance, Reporting and Control disease-reporting -> Guide to surveillance, reporting and control Download 25.71 Kb. Share with your friends:
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