DECLARATION AND/OR AFFIDAVIT UNDER PENALTY OF PERJURY

OF MEDICAL OFFICER IN SUPPORT OF ISOLATION AND/OR QUARANTINE ORDER

I, _____________, do hereby (declare/attest) that:

1) I am the [List Title and Medical Degree] of the [List name of State and/or Local Health Department]. I have served in this capacity since my installation in (month) (year).

2) The primary mission of [Insert name of State and/or Local Health Department] is to [Insert mission of State and/or Local Health Department, e.g., reduce morbidity and mortality in State/County/City of ___].

3) Since [Insert date], [Insert name of State and/or Local Health Department] has been tracking reports of outbreaks of a respiratory illness called Severe Acute Respiratory Syndrome (SARS).

4) Upon information and belief, as of [Insert date], the World Health Organization (WHO) has reported [Insert number] possible cases of SARS worldwide with [Insert number] deaths. In the United States, the Centers for Disease Control and Prevention (CDC), a component of the U.S. Department of Health and Human Services has reported [Insert number] of possible SARS cases in the United States with [Insert number] deaths.

5) There is currently no specific medical treatment for SARS and the disease is potentially fatal.

6) The primary way that SARS appears to spread is by close person-to-person contact. Most cases of SARS have involved people who cared for or lived with someone with SARS, or had direct contact with infectious material (for example, respiratory secretions) from a person who has SARS. Potential ways in which SARS can be spread include touching the skin of other persons or objects that are contaminated with infectious droplets and then touching the eye, nose, or mouth. This can happen when someone who is sick with SARS coughs or sneezes droplets onto themselves, other persons, or nearby surfaces. It is also possible that SARS can be spread more broadly through the air or by other ways that are currently not known.

7) Upon information and belief, CDC has recommended that SARS patients in the United States be [isolated and/or quarantined] until they are no longer potentially infectious. Isolation refers to the separation of persons with symptoms showing that they are potentially infected with a disease while quarantine refers to the separation of persons who may have been exposed to the disease, but are not yet displaying symptoms. Quarantine and isolation are public health measures that allow patients to receive appropriate care and contain the potential spread of illness. Those who are more severely ill are being cared for in hospitals. Those whose illness is mild are being cared for at home. Individuals being cared for at home have been asked to avoid contact with other people and to remain at home until [10 days] after the resolution of fever, provided respiratory symptoms are absent or improving.

8) Upon information and belief, CDC classifies individuals believed to be infected with SARS into either “suspect” cases or “probable” cases. CDC defines suspect and probable cases based on three factors: 1) clinical criteria; 2) epidemiologic criteria; and 3) laboratory criteria. [Insert name of State and/or local health department] is currently monitoring [Insert number] possible cases of SARS in the United States of which, according to criteria established by CDC, [Insert number] are “suspect” cases and [Insert number] are “probable” cases.

9) Upon information and belief, CDC defines a suspect case of SARS as anyone meeting: 1) clinical criteria for moderate respiratory illness of unknown etiology with onset since [Insert date]; 2) epidemiologic criteria; and 3) laboratory criteria.

10) Upon information and belief, CDC defines a probable case of SARS as anyone meeting: 1) clinical criteria for severe respiratory illness of unknown etiology with onset since February 1, 2003, 2) epidemiologic criteria; and 3) laboratory criteria.

11) Upon information and belief, CDC’s clinical criteria for moderate respiratory illness are temperature of greater than 100.4º F (greater than 38º C), and one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia).

12) Upon information and belief, CDC’s clinical criteria for severe respiratory illness are temperature of greater than 100.4º F (greater than 38º C), and one or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia), and radiographic evidence of pneumonia, or respiratory distress syndrome, or autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause.

13) Upon information and belief, CDC’s epidemiologic criteria for SARS are travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or recently documented or suspected community transmission of SARS, or close contact within 10 days of onset of symptoms with a person known or suspected to have SARS infection

14) Upon information and belief, the laboratory criteria that CDC uses to detect SARS may fall into three categories: confirmed, negative, or undetermined. Laboratory testing that detects: 1) antibody to SARS-CoV (SARS-Coronovirus) in specimens obtained during acute illness or greater than 21 days after illness onset; or 2) SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the specimen and a different set of PCR primers; or 3) Isolation of SARS-CoV; indicates laboratory confirmation for SARS. The absence of antibody to SARS-CoV in convalescent serum obtained greater than 21 days after symptom onset indicates negative laboratory presence for SARS, but does not exclude the presence of the disease in the individual. Laboratory testing that has either not been performed or is incomplete indicates undetermined laboratory presence for SARS.

15) [Insert name of subject] falls into the CDC classification of a [suspect or probable] case of SARS.

16) It is my professional judgment, based upon the information and evidence cited herein, that [Insert name of subject] is infected with or has been exposed to a communicable disease for which isolation and/or quarantine is authorized pursuant to [Insert State and/or legal authority for isolation and/or quarantine].

17) I reach this conclusion based on the following evidence [state the clinical, epidemiologic, and laboratory evidence indicative of SARS, e.g., travel history and other relevant information]. [State further information needed to determine whether case is suspect or probable, e.g., further laboratory testing, etc.]

18) Upon information and belief, [Insert information regarding whether the subject is recalcitrant, unlikely to comply with voluntary measures, etc.]

19) Based upon the relevant criteria, [Insert name of subject] should be [quarantined and/or isolated] until he/she is no longer potentially infectious in order to contain the spread of the disease. [Insert information regarding whether suspect should be isolated at home or in a hospital or other facility]. [Insert precautions that should be taken by household contact, law enforcement, etc.].

20) Accordingly, pursuant to [Insert State and/or legal authority for isolation and/or quarantine] on [insert date and time] I have recommended the issuance of an isolation and/or quarantine order, requiring that [insert name of subject] remain in isolation and/or quarantine at [insert name of facility or home address] until [insert date and time when isolation/quarantine ends] be issued.

In accordance with [Insert legal provision authorizing issuance of declarations and/or affidavits (signatures pursuant to affidavit generally require a notary)], I declare/attest under penalty of perjury that the foregoing is true and correct to the best of my knowledge and belief.

Signed this ________________ day of _________________, 2003.

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[Insert Name and Title of Authorizing Official]