N.Y. Comp. Codes R. & Regs. tit. 14, Appendices, app 12, FORMS FOR ARTICLE 730 CRIMINAL PROCEDURE LAW, form A
It is my opinion that the above-named defendant is an incapacitated person in that the said defendant as a result of mental disease or defect lacks capacity to understand the proceeding against him or to assist in his own defense. My opinion is based on the following:
(NOTE TO EXAMINER: If the order of examination has been issued by the Supreme Court or the County Court you must also complete the following, setting forth your opinion as to whether the defendant is, or is not, a dangerous incapacitated person.)
It is my further opinion that the above-named defendant (is) (is not) a dangerous incapacitated person, that is, an incapacitated person who is so mentally ill or mentally defective that his presence in an institution operated by the Department of Mental Hygiene is dangerous to the safety of other patients therein, the staff of the institution or the community. The following is a detailed statement of the reasons for finding the defendant to be a dangerous incapacitated person. (NOTE: No statement is necessary if defendant is not so found).
SIGNATURE:____________, DATED:____________,19________
(Print name)
(Qualified Psychiatrist) (Certified
Psychologist)
(STRIKE OUT ONE)
CERTIFICATE OF SERVICE
A copy of this application was personally served upon the said defendant on the ________ day of ________, 19 ________, with a notice of his right to request a hearing and copies thereof have been served by mail upon the Mental Health Information Service, the District Attorney of ________ county and ________.
____________
Dated ________
____________
Signature of Hospital Director
____________
Printed Name
____________
Hospital
N.Y. Comp. Codes R. & Regs. tit. 14, Appendices, app 12, FORMS FOR ARTICLE 730 CRIMINAL PROCEDURE LAW, form A