Certificate For Transport To Emergency Receiving Facility (Page 2 of 3) in pdf

REPORT OF PEACE OFFICER OR OTHER PERSON PROVIDING TRANSPORTATION

STATE OF GEORGIA, COUNTY OF______________________________

DATE ________________

NAME OF INDIVIDUAL TRANSPORTED:____________________________________________________

When transportation is provided by a Peace Officer, Sections 37-3-41 and 37-3-42 of the Official Code of Georgia

Annotated require that the Peace Officer complete a written report detailing the circumstances under which the

individual was taken into custody for mental health transportation. When transportation is provided by any person or

entity other than a Peace Officer, this report is necessary to assist the receiving facility in caring for the health and

safety of the individual transported, and of other persons at the facility.

To Emergency Receiving Facility known as _______________________________________ I report as follows:

Time and Date of pickup: _________________________ Location: ___________________________

Behavior observed at that time:

_________________________________________________________________________________________

While under my observation the conditions checked below were present:

[

] Made threats to harm self

[

] Appeared calm

[

] Unable/refused to speak

[

] Made threats to harm others

[

] Appeared upset

[

] Attempted to injure or injured self

[

] Knew where he/she was

[

] Was cooperative

[

] Attempted to injure or injured someone else

[

] Knew who he/she was

[

] Was combative

[

] Knew the approximate time and date

Name and address of family or others who were present when the Individual was taken into custody:

Name: ____________________________________________________

Relationship:__________________

Address:_________________________________________________________________________________

COMMENTS or INFORMATION from family or others having personal knowledge of Individual:

_________________________________________________________________________________________

Physical restraints utilized during transportation, if any:

_________________________________________________________________________________________

Individual’s physical condition (apparent injuries, illness or distress):

_________________________________________________________________________________________

Other information:

_________________________________________________________________________________________

Transportation provided by:

[ ] Relative of the Individual: Name & Relationship:___________________________________________________________

[ ] Ambulance service: Name of company___________________________________________________________________

Operated by (Hospital or provider name):_________________________________________________

[ ] Transportation company or provider: Name_______________________________________________________________

Operated by__________________________________________________________

[ ] Peace Officer for (Jurisdiction) _________________________________________________________

If transportation was provided by a Peace Officer, it was under the authority of:

[ ] Emergency Certificate (1013)

[ ] Probate Court order

_________________________________________

TIME delivered to Emergency Receiving Facility

DATE delivered to Emergency Receiving Facility

_________________________________________

__________________________________________

PRINTED Name of Peace Officer or Other Person

SIGNATURE of Peace Officer or Other Person

Form 1013 – Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation – Mental Health

DBHDD By Authority of O.C.G.A. § 37-3-41, 37-3-42 & 37-3-101 -Form Last Revised 03.20.2012; Effective 03.31.2012- Page 2 of 2

Certificate For Transport To Emergency Receiving Facility Page 2

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