CERTIFICATION BY PEACE OFFICER
I am a sheriff, deputy sheriff, State police officer, county police officer, municipal or
other local police officer, or Secret Service agent who is a sworn special agent of the United States
Secret Service or Treasury Department authorized to exercise powers delegated under 18 U.S.C. § 3056.
As to............................................................................................................. (evaluee), I have personally
observed the evaluee or evaluee's behavior and, based on the observation or other
information, have reason to believe that the evaluee has a mental disorder and presents a danger to the life
or safety of the evaluee or others. Pursuant to Maryland Code, Health–General Article § 10-622, I have
transported the evaluee to ...............................................................................................................................
(emergency facility) for evaluation.
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CERTIFICATIONS BY
OTHER PERSON QUALIFIED UNDER HG § 10-622 AND PEACE OFFICER
I am a physician, psychologist, clinical social worker, licensed clinical professional counselor,
clinical nurse specialist in psychiatric and mental health nursing, psychiatric nurse practitioner, health
officer or designee of a health officer. I have examined................................................................................
.......................................(evaluee). Based on the examination or other information, I have reason to
believe that the evaluee has a mental disorder and presents a danger to the life or safety of the evaluee or others
and, in accordance with Maryland Code, Health–General Article § 10-622, have completed the attached
Petition for Emergency Evaluation and have