Part 2 Has the AMHP completing part 2 entered ☐ ☐ their full name and address on the form? Yes No Has the AMHP entered the name of the ☐ ☐ Yes No authority on whose behalf they are acting? ☐ ☐ Where the AMHP is not approved by that Yes No authority (above) have they entered the name of the local authority that approved them (and made the necessary deletion)? Has the AMHP completing the form signed ☐ ☐ Yes No and dated the form? Is the date of the AMHPs signature the ☐ ☐ Yes No same or later than the date or the RCs signature in Part 1 and prior to the date the CTO would expire if not extended? Part 3 Has the RC entered the name and ☐ ☐ profession of the person they have Yes No consulted? Is the person that was consulted by the RC ☐ ☐ different to the person completing part 2? Yes No Has the RC indicated how he/she is ☐ ☐ furnishing the report by deleting the phrase Yes No that does not apply? Has Part 3 been signed and dated by the ☐ ☐ RC? Yes No Is the date of the RCs signature in this part ☐ ☐ Yes No the same or later than the signatures at Part 1 & 2 of the form and prior to the date the CTO would expire if not extended? Part 4 ☐ ☐ Has Part 4 been completed including Yes No signed, name printed and Has the necessary deletion been made? □ ☐ Yes No Is the date on this part of the form the same ☐ ☐ or later than the dates of all of the signatures Yes No in parts 1, 2 and 3?
Part 2 Has the AMHP completing part 2 entered their full name and address on the form? ☐ Yes ☐ No Has the AMHP entered the name of the authority on whose behalf they are acting? ☐ Yes ☐ No Where the AMHP is not approved by that authority (above) have they entered the name of the local authority that approved them (and made the necessary deletion)? ☐ Yes ☐ No Has the AMHP completing the form signed and dated the form? ☐ Yes ☐ No Is the date of the AMHPs signature the same or later than the date or the RCs signature in Part 1 and prior to the date the CTO would expire if not extended? ☐ Yes ☐ No Part 3 Has the RC entered the name and profession of the person they have consulted? ☐ Yes ☐ No Is the person that was consulted by the RC different to the person completing part 2? ☐ Yes ☐ No Has the RC indicated how he/she is furnishing the report by deleting the phrase that does not apply? ☐ Yes ☐ No Has Part 3 been signed and dated by the RC? ☐ Yes ☐ No Is the date of the RCs signature in this part the same or later than the signatures at Part 1 & 2 of the form and prior to the date the CTO would expire if not extended? ☐ Yes ☐ No Part 4 Has Part 4 been completed including ☐ Yes ☐ No signed, name printed and Has the necessary deletion been made? □ Yes ☐ No Is the date on this part of the form the same or later than the dates of all of the signatures ☐ Yes ☐ No in parts 1, 2 and 3?
MHA-PGN-08-App15-Clist-Sec20A-ExtCTO-V01-Iss1-IssFeb16.docx