SOP 203.03-att-1: Incident Report Form (Attachment 1)

Division:
Facilities
Effective Date:
April 1, 2025
Reference Code:
IIA04-0002
Topic Area:
203 Policy-Facilities Reporting/Operations
PowerDMS:
View on PowerDMS
Length:
300 words

Summary

This is the standard incident report form used by the Georgia Department of Corrections to document all incidents occurring at correctional facilities. Staff members must complete this form to record incident details including type of incident, individuals involved, use of force, injuries, contraband, and notifications made. The form is reviewed and approved by facility leadership and retained for three years.

Key Topics

  • incident report
  • facility incident
  • use of force
  • inmate injury
  • staff injury
  • contraband
  • weapon
  • cell extraction
  • assault
  • escape attempt
  • PREA allegation
  • medical emergency
  • injury documentation
  • incident investigation
  • facility operations
  • emergency response

Full Text

SOP 203.03

Incident Report Attachment 1
04/01/2025

Major Minor

Incident ID:

Facility:

Incident Date: Time:

Location/Dorm:

Operator Name:

Did incident result in serious injury? (Outside Medical Care) No Staff Inmate

Video Used? Y N If Yes, Type? Handheld Body Building Phone/Tablet Other

Evidence of Weapon Used? Y N If Yes, was it Found Not Found

Use of Force? Y N UOF Equipment Used? Y N Taser Chemical Firearm Hands-On Other:

Does this incident report contain hard contraband? Y N If Yes, it was found: Inside Grounds Outside Grounds

Is the contraband associated with a throw-over? Y N

Incident Category: Check all that apply:

Accident Escape- Secure Facility Detail TC Inmate Internet Violation Property
Attempted Suicide Escape Attempt Inmate Special Transport Quarantine
Cell Extraction Failure to Execute Policy Inmate Strip Cell Status Self-Injurious Behavior
Contraband - Hard Fight Inmate to Inmate Assault Shakedown
Contraband - Nuisance Fire Incident Inmate to Staff Assault Staff Shakedown
Damaged Property Flooding Institutional Drill Staff to Staff Assault
Death Four/Five Point Restraint Keys/Tools Suicide
Disruptive Behavior Homicide Maintenance Incident Taking Hostage
Disruptive Event Hunger Strike Personal Dealings with Inmate Unauthorized Contact
Drone Illness PREA - Allegation Use of Force
Employee Contact with Blood Injury Projecting Bodily Fluids Visitor Incident

Directly Involved

OR
Witness

Involved Witness

Involved INMATE Name GDC # UOF DR

Injury

Sex.
Weapon
Alleg.

Involved

Involved

Involved

Involved

Involved

Involved

Involved

Witness

Witness
Witness
Witness
Witness
Witness
Witness

Involved Staff Name / Title Employee ID# Race Sex Force Used Staff Equip. Equip. Type

WITNESS Name Number / Title WITNESS Name Number / Title

Number / Title

WITNESS Name

Name/Agency Notified Date Time Name/Agency Notified Date Time

Reporting Official Signature: Date: Supervisor Signature:

WARDEN / SUPERINTENDENT REVIEW: Was this incident forwarded for investigation? Yes No

Date:

Warden's Comments:

Warden/Superintendent Signature

Date

Retention Schedule: (3) years and then destroy.

Attachments (2)

  1. Incident Report Form (Attachment 1) (300 words)
  2. Incident Report Supplement Form (26 words)
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