COMMONWEALTH OF MASSACHUSETTS
SUFFOLK [OR THE SUPERIOR COURT
COUNTY WHERE DEFENDANT C.A. No. __________
COMMONWEALTH OF MASSACHUSETTS, BY )
AND THROUGH JOHN M. AUERBACH, )
COMMISSIONER OF PUBLIC HEALTH, and )
BOARD OF HEALTH OF THE CITY )
OR TOWN OF [ _______________________] )
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.
Created on 3/30/04, Modified 2008 1
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
[list number of cases treated and any other skill or experience with SARS].
Created on 3/30/04, Modified 2008 2
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
Created on 3/30/04, Modified 2008 3
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.
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.
My Commission Expires: _____________________
A COPY OF THIS AFFIDAVIT MUST BE SERVED UPON THE PERSON TO BE
CONFINED AND UPON HIS/HER LEGAL COUNSEL.
Created on 3/30/04, Modified 2008 4