REPORT OF LAW ENFORCEMENT OFFICER INITIATING PROTECTIVE CUSTODY
IN AND FOR HILLSBOROUGH COUNTY, 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:

[] He/she 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:


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(Signature of Law Enforcement Officer)


TRANSPORTATION TO SUBSTANCE ABUSE PROVIDER:

Location Found: Taken To:

Family members or others present when person was taken into custody:

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Next of Kin, if known:

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Indicate personal knowledge by family members and others about the person’s condition: