SOP_NUMBER: 209.04-att-2
TITLE: Use of Force Incident Report
REFERENCE_CODE: IIB08-0001
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2021-02-18
WORD_COUNT: 310
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105932
URL: https://gps.press/sop-data/209.04-att-2/

SUMMARY:
This is a standardized incident report form used to document any use of force incidents occurring at GDC facilities. The form captures detailed information about the incident including date, time, location, personnel involved, types of force used, injuries sustained, and weapons involved. It requires reporting by facility staff and review/approval by supervisory and warden-level personnel.

KEY_TOPICS: use of force, incident report, UOF, taser, chemical agents, firearm, hands-on force, serious injury, force equipment, incident documentation, facility incident, inmate assault, staff assault, cell extraction, restraints, contraband, shakedown, video documentation

ATTACHMENTS:
  1. Use of Force Supplement Report
     URL: https://gps.press/sop-data/209.04-att-1/
  2. Use of Force Incident Report
     URL: https://gps.press/sop-data/209.04-att-2/
  3. Use of Force Coversheet_Checklist
     URL: https://gps.press/sop-data/209.04-att-3/
  4. Conducted Electrical Weapon (Taser) Weekly Usage Report Example
     URL: https://gps.press/sop-data/209.04-att-4/
  5. Official Witness Statement Form
     URL: https://gps.press/sop-data/209.04-att-5/
  6. Restraint Chair Authorization Form
     URL: https://gps.press/sop-data/209.04-att-6/

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FULL TEXT:
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SOP 209.04

**Incident Report** Attachment 2
2/18/21

Major Minor



Incident ID:



Facility:



Incident Date: Time:



Location/Dorm:



Reporting Official: Video Used? Y N


Did incident result in serious injury? No Staff Inmate


Offender Weapon? Y N Weapon Description:



Operator Name:



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


Does this incident report contain 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 Inmate Special Transport Self-Injurious Behavior
Attempted Suicide Escape Attempt Inmate Strip Cell Status Shakedown
Cell Extraction Failure to Execute Policy Inmate to Inmate Assault Staff Shakedown
Contraband - Hard Fight Inmate to Staff Assault Staff to Staff Assault
Contraband - Nuisance Fire Incident Institutional Drill Suicide
Death Four/Five Point Restraint Keys/Tools Taking Hostage
Disruptive Behavior Homicide Maintenance Incident Unauthorized Contact
Disruptive Event Hunger Strike Personal Dealings with Inmate Use of Force
Drugs Illness PREA - Allegation Visitor Incident
Employee Contact with Blood Injury Projecting Bodily Fluids Wireless Device
Inmate Internet Violation Property Wireless Device Accessory



**Directly Involved**

**OR**
**Witness**

Involved Witness
Involved Witness



**Involved INMATE Name** **GDC #** **UOF** **DR**



**Injury**



**Sex.**
**Weapon**
**Alleg.**



Involved
Involved

Involved

Involved

Involved

Involved



Witness
Witness
Witness
Witness
Witness
Witness



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



**Employee ID#** **Race** **Sex**



**Race**



**WITNESS Name**


**Name/Agency Notified**


**Reporting Official Signature:**



**Number / Title**



**Date:**



**WITNESS Name**



**Number / Title**



**Date**



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



**Supervisor Signature:**



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



**Date:**


Warden's Comments:



**Warden/Superintendent Signature**



**Date**



**Retention Schedule: A copy shall be maintained in the offender's**
**institutional file and retained according to the official retention record for**
**that file. Copies maintained in Security shall be retained for three (3) years**
**and then destroyed.**