Form CIV-790 "Application for Ex Parte Order for Testing, Examination, or Screening" - Alaska

What Is Form CIV-790?

This is a legal form that was released by the Alaska Court System - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Alaska Court System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CIV-790 by clicking the link below or browse more documents and templates provided by the Alaska Court System.

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Download Form CIV-790 "Application for Ex Parte Order for Testing, Examination, or Screening" - Alaska

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IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA
AT
)
)
)
Petitioner,
)
Case No.
CI
vs.
)
EX PARTE
)
APPLICATION FOR
)
ORDER FOR TESTING,
Respondent.
Minor
)
EXAMINATION, OR SCREENING
)
[AS 18.15.375(c)-(e)]
Applicant Name:
Applicant Title:
Applicant Agency:
1.
I am the applicant named above. I am authorized to make this application on
behalf of the Alaska Department of Health and Social Services, Division of Public
Health (the Department) or other authorized municipal agency (Agency).
2.
A medical officer from the State of Alaska or local municipality determined that the
respondent has or may have been exposed to this contagious disease:
, and determined that this condition poses a
significant risk to the public health.
The following facts support these determinations:
3.
This condition may be avoided, cured, alleviated, or made less contagious through
safe and effective treatment, modifications in individual behavior, or public health
intervention.
4.
A medical officer from the State of Alaska or local municipality issued an
administrative order requiring the respondent to undergo testing, examination, or
screening. The administrative order was personally served on the respondent
pursuant to AS 18.15.375(c)(2).
5.
The respondent is under age 18. Parent’s name and address:
Name:
Address:
Cell Phone:
Other Phone:
Email:
The respondent has a legal guardian. Legal guardian’s name and address:
Name:
Page 1 of 2
AS 18.15.375(c)-(e)
CIV-790 (4/20)(cs)
EX PARTE
APPLICATION FOR
ORDER
IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA
AT
)
)
)
Petitioner,
)
Case No.
CI
vs.
)
EX PARTE
)
APPLICATION FOR
)
ORDER FOR TESTING,
Respondent.
Minor
)
EXAMINATION, OR SCREENING
)
[AS 18.15.375(c)-(e)]
Applicant Name:
Applicant Title:
Applicant Agency:
1.
I am the applicant named above. I am authorized to make this application on
behalf of the Alaska Department of Health and Social Services, Division of Public
Health (the Department) or other authorized municipal agency (Agency).
2.
A medical officer from the State of Alaska or local municipality determined that the
respondent has or may have been exposed to this contagious disease:
, and determined that this condition poses a
significant risk to the public health.
The following facts support these determinations:
3.
This condition may be avoided, cured, alleviated, or made less contagious through
safe and effective treatment, modifications in individual behavior, or public health
intervention.
4.
A medical officer from the State of Alaska or local municipality issued an
administrative order requiring the respondent to undergo testing, examination, or
screening. The administrative order was personally served on the respondent
pursuant to AS 18.15.375(c)(2).
5.
The respondent is under age 18. Parent’s name and address:
Name:
Address:
Cell Phone:
Other Phone:
Email:
The respondent has a legal guardian. Legal guardian’s name and address:
Name:
Page 1 of 2
AS 18.15.375(c)-(e)
CIV-790 (4/20)(cs)
EX PARTE
APPLICATION FOR
ORDER
Address:
Cell Phone:
Other Phone:
Email:
6.
The respondent or the respondent’s legal guardian:
objects to the administrative order of the state medical officer; or
cannot be reached to give consent to the administrative order; or
lacks the capacity to consent or object to the administrative order because:
7.
The respondent is currently:
detained under an order of isolation or quarantine, and has been detained
since (date)
.
not detained.
I request that the court order a peace officer to take the
respondent into protective custody until a hearing is held.
8.
I believe the respondent is currently located at:
ex parte
9.
I request that the court issue an
order for testing, examination or
screening the respondent for the condition listed above.
I say on oath or affirm that I read this document and believe all statements made in the
document are true.
Signature of Applicant
Phone
Print Name
Fax
Address Line 1
Email
Address Line 2
Subscribed and sworn to or affirmed before me at
, Alaska
on ___________________.
(date)
Clerk of Court, Notary Public or other person
(SEAL)
Authorized to administer oaths.
My Commission Expires:
Page 2 of 2
AS 18.15.375(c)-(e)
CIV-790 (4/20)(cs)
EX PARTE
APPLICATION FOR
ORDER
Page of 2