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Certification By Peace Officer And Certifications By Other Qualified Person And Peace Officer CC-DC 14 - Maryland
| Certification By Peace Officer And Certifications By Other Qualified Person And Peace Officer Form. This is a Maryland form and can be used in General Circuit-District Court Statewide . |
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CERTIFICATIONBY PEACEOFFICER Ia ma sheriff, deputysheriff, Statepoliceofficer, countypoliceofficer, municipalor otherlocalpoliceofficer,or SecretServiceagentwhois a swornspecialagentof the UnitedStates SecretServiceor TreasuryDepartmentauthorizedto exercisepowersdelegatedunder18 U.S.C. 3056. As to.............................................................................................................(evaluee),I have personallyobservedthe evalueeor evalueesbehaviorand, basedon the observationor other information,have reasonto believethatthe evalueehas a mentaldisorderand presentsa dangerto the life or safetyof the evalueeor others.Pursuantto MarylandCode,HealthGeneralArticle 10-622,I have transportedthe evalueeto ...............................................................................................................................(emergencyfacility)for evaluation. ............................................................................................................................................................................ DateandTime PeaceOfficer ...................................................................................... Department I.D.No. CERTIFICATIONSBY OTHERPERSONQUALIFIEDUNDERHG 10-622AND PEACE OFFICER Ia ma physician, psychologist, clinicalsocialworker, licensedclinicalprofessionalcounselor, clinicalnursespecialistin psychiatricandmentalhealthnursing, psychiatricnursepractitioner, health officeror designeeof a healthofficer.I haveexamined.......................................................................................................................(evaluee).Basedon theexaminationor otherinformation,I havereasontobelievethattheevalueehasa mentaldisorderandpresentsa dangerto thelifeor safetyof the evalueeor others and,in accordancewithMarylandCode,HealthGeneralArticle 10-622,havecompletedtheattached PetitionforEmergencyEvaluationandhaverequesteda peaceofficertotakeintocustodyandtransportthe evalueeto thenearestemergencyfacilityforevaluationby a physician.Thepeaceofficerexplainedto me the seriousnature,meaning,andcontentof thepetitionandI askedtheofficertoproceed. ............................................................................................................................................................................DateandTimePhysicianor otherQualifiedPersonunderHG 10-622 ...................................................................................... LicenseNo. I haveexplainedto the Petitionerthe seriousnatureof the petitionandthe meaningand contentof the petition.............................................................................................................................................................................DatePeaceOfficer ......................................................................................DepartmentI.D.No.CC-DC14 (Rev.10/2004)
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