State of West Virginia, Office of ..........................
County (or City) of ......... County (or City) of ..........
.......................... Officer.
To................, Chief of Police or Sheriff of .......... City, of County of ...............:
It having been brought to the attention of the undersigned health officer for (city or county) of ................, West Virginia, that .............., reported as living or residing at ............... in (city or county), is infected, or is reasonably suspected of being infected, with one or more sexually transmitted diseases by reason of the fact that .................. has been reported as (set out any reasons set in section fourteen of this article, or other reasons)
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and therefore reasonably suspected of being infected; and as the diseases have been declared to be infectious, contagious, communicable and dangerous to the public health.
This warrant commands you to apprehend ......................, if found within your jurisdiction, and to bring ................ before me at my office in the city or county of .................. on the .............. day of ..............., 19 ...., at ........ o'clock, .... M, there to be further dealt with as provided by law.
Given under my hand, this the ..................... day of ................., 19 .....
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Health Officer or Commissioner.
City (or County) of ........................................
West Virginia.
W. Va. Code § 16-4-15