Physician's or Other Health Care Provider’s Affidavit of Medical by lyk18840

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									                              COMMONWEALTH OF MASSACHUSETTS

SUFFOLK [OR THE                                                   SUPERIOR COURT
COUNTY WHERE DEFENDANT                                            C.A. No. __________
LIVES], ss.
____________________________________________
                                                           )
COMMONWEALTH OF MASSACHUSETTS, BY                          )
AND THROUGH JOHN M. AUERBACH,      )
COMMISSIONER OF PUBLIC HEALTH, and                         )
                                                           )
BOARD OF HEALTH OF THE CITY                                )
OR TOWN OF [ _______________________]                      )
                                                           )
                                                           )
                Plaintiffs                                 )
                                                           )
                         v.                                )
                                                           )
_____________________________                              )
NAME OF INDIVIDUAL                                         )
WHOSE ISOLATION IS SOUGHT                                  )
                                                           )
                                                           )
                Defendant (Patient)                        )
                                                           )

PHYSICIAN’S OR OTHER HEALTH CARE PROVIDER’S AFFIDAVIT OF MEDICAL
             EXAMINATION, TREATMENT, OR EVALUATION

        I, _______________________________, the undersigned, a physician or health care

provider as defined in G.L. c. 111, § 1, and 105 CMR 300.020, 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.

                                          EXHIBIT A




Created on 3/30/04, Modified 2008                                                               1
Affidavit_by_MD_of_SARS_Pt_Med_Exam_or_Treatment_or_Eval
        2.      I am currently a [SELECT ONE: physician, nurse, other health care provider] with

an office at ______________________________. I have been a

______________________________ for _______________ years.

        3.      My statements concerning ____________________________________________

are made based on my personal knowledge from examining or treating __________________,

except where noted.

        4.      I have been involved in ________________________’s examination or treatment

on the following dates or during the following periods:

_____________________________________________________________________________.

        5.      My education and training concerning the communicable disease known as Severe

Acute Respiratory Syndrome (SARS), is as follows:

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________.

        6.      My experience in diagnosing or treating SARS is as follows [delete this if there is

no experience]:

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________.

[list number of cases treated and any other skill or experience with SARS].

                                           EXHIBIT A




Created on 3/30/04, Modified 2008                                                                 2
Affidavit_by_MD_of_SARS_Pt_Med_Exam_or_Treatment_or_Eval
        7.      _________________________________ is a probable or suspect case of SARS,

which is a communicable disease.

        8.      The basis of my finding that _______________________________ is a probable

or suspect case of SARS is:

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________.

        9.      The basis of my finding that _____________________ has a communicable

disease is that [CHECK ALL THAT APPLY]:

               Insufficient time has passed and/or insufficient treatment has been provided to

permit the disease to improve to a non-communicable state;

               Visual observation of ___________________during the following

dates_____________ showed that [LIST SYMPTOMS]:

_____________________________________________________________________________

               A positive result on a laboratory test of a ___________ sample provided by

______________________ during the following periods or on the following dates. This result

indicates that ________________________________________________________________.

        10.     My training and experience have included the following information about SARS:

SARS is caused by a coronavirus. SARS patients are communicable from the onset of symptoms

to ten days following resolution of fever and until their respiratory symptoms have resolved or

                                           EXHIBIT A




Created on 3/30/04, Modified 2008                                                                 3
Affidavit_by_MD_of_SARS_Pt_Med_Exam_or_Treatment_or_Eval
significantly improved. Transmission occurs through close contact with a symptomatic

individual. SARS can be fatal. A person who becomes infected with the SARS coronavirus

remains infected for fourteen to twenty-eight days, but is usually able to eliminate the infection

by ten days after resolution of fever and improvement in symptoms. Persons exposed to SARS

may develop SARS.

                                              Signed: ___________________________________

                                              Physician or Health Care Provider



On this ___ day of _____, 20___, before me, the undersigned notary public, personally appeared
_______________________________, proved to me through satisfactory evidence of
identification, which were ______________________, to be the person whose name is signed on
the preceding or attached document, and who swore or affirmed to me that the contents of the
document are truthful and accurate to the best of his/her knowledge an belief.

                                              __________________________________________
                                              Notary Public




My Commission Expires: _____________________




A COPY OF THIS AFFIDAVIT MUST BE SERVED UPON THE PERSON TO BE
CONFINED AND UPON HIS/HER LEGAL COUNSEL.


                                           EXHIBIT A



Created on 3/30/04, Modified 2008                                                                    4
Affidavit_by_MD_of_SARS_Pt_Med_Exam_or_Treatment_or_Eval

								
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