SOP 209.04-att-3: Use of Force Coversheet_Checklist

SOP 209.04
Attachment 3

2/18/21

____________________________________________ Facility/Center

Use of Force/Serious Incident Report Coversheet

I. Offender Name_________________________________ Date: ____________________

II. Checklist:

1. Use of Force………………………………………………………. Yes______ No _____Pending _____
2. Incident Report…………………………………………………… Yes______ No _____Pending _____
3. Supplemental Use of Force………………………………………. Yes______ No _____Pending _____
4. Videotape…………………………………………………………. Yes ______ No_____ Pending _____
5. Photos……………………………………………………………... Yes ______No _____Pending _____
6. Witness statements from all involved………………………………Yes ______No _____Pending _____
7. Disciplinary Report filed…………………………………………...Yes ______No _____Pending _____
8. Medical Reports……………………………………………………Yes ______No _____Pending _____
9. Mental Health Report/Statements…………………………………. Yes______ No _____Pending _____
10. Chain of Evidence………………………………………………… Yes______ No _____Pending _____
11. Use of Weapons Report…………………………………………… Yes______ No _____Pending _____

If pending is checked on any of the above, state the reason why:

III. Shift Supervisor: 1. Date submitted and forwarded to Captain: _____________________

2. Supervisor’s Signature: _________________________________________________________

IV. Captain/Chief of Security Review: 1. Date received: _________ 2. Date videotape reviewed: _______

3. Rating of Incident: Major: Serious: Minor: Unusual:

4. Comments:

5. Signature of Captain/Chief of Security:

V. Deputy Warden’s Review: 1. Date received 2. Date videotape reviewed:

3. Comments:

4. Signature of Deputy Warden:

VI. Warden’s Review: 1. Date received: _____________ 2. Type and Forward: Y N Hold in File: Y N

3. Comments:

4. Signature of Warden/Designee:

Retention Schedule: Upon completion, this form shall be placed in the offender’s institutional file, with the incident
report, and retained according to the official retention schedule for that file.