Special Pickup Information {50.1}

PC-MI-50.1 (Rev. 12-2000) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY,JUDGE LAWRENCE A. BELSKIS, JUDGE IN THE MATTER OF CASE NO. SPECIAL PICKUP INFORMATION Age: Height.: Weight.: S.S.N.: Location of Patient: Transport to: Yes, explain below Weapons available? ................................... Likely to resist? .......................................... Handicapped? ............................................ Past history of mental illness? ................... Past criminal record? ................................. Possible dangerous situation? .................. Contagious disease? ................................. ................................ ................................ ................................ ................................ ................................ ................................ ................................ No Unknown .......................... .......................... .......................... .......................... .......................... .......................... .......................... Race: Eyes (color): Hair (color): D.O.B.: Health Officer/Pre-screener: Other: Telephone No.: Date FRANKLIN COUNTY FORM 50.1 - SPECIAL PICKUP INFORMATION Affiant American LegalNet, Inc. www.FormsWorkFlow.com