Form Ma-3 - Report Of Law Enforcement Officer Initiating Protective Custody - State Of Florida


MA-3 Report of Law Enforcement Officer Initiating Protective Custody MA
Report of Law Enforcement Officer Initiating Protective Custody
State of Florida, County of ______________________, Florida
I,_____________________________________, am a law enforcement officer certified by the State of Florida. I
have good faith reason to believe that ______________________________________________ appears to meet
the following criteria for protective custody:
is substance abuse impaired and, because of such impairment:
Has lost the power of self-control with respect to substance use; and either
Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on
himself or herself or another; or
Is in need of substance abuse services and, by reason of substance abuse impairment, his or her judgment
has been so impaired that the person is incapable of appreciating his or her need for such services and of
making a rational decision in regard thereto; however, mere refusal to receive such services does not
constitute evidence of lack of judgment with respect to his or her need for such services.
Circumstances which support this opinion: _________________________________________________________
____ am pm
Signature of Law Enforcement Officer
Date (mm/dd/yyyy)
Printed Name of Law Enforcement Officer
Full Name of Law Enforcement Agency
Badge or ID Number
Law Enforcement Case Number
Transportation to Substance Abuse Provider
Location Found:
Taken To:
Family members or others present when person was taken into custody
Phone Number
Next of Kin (if known)
Indicate personal knowledge by family members and others about the person’s condition
By Authority of s. 397.677, Florida Statutes
Marchman Act Handbook Page 259


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