SOP_NUMBER: 210.03-att-3 TITLE: Medical Checklist for Screening Prospective Participants in the Detention Center and Probation Boot Camp Program REFERENCE_CODE: IIB12-0003 DIVISION: Facilities TOPIC_AREA: 210 Policy-Probation Boot Camp EFFECTIVE_DATE: 2015-07-15 WORD_COUNT: 1311 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/106061 URL: https://gps.press/sop-data/210.03-att-3/ SUMMARY: This medical screening form is used to assess the physical and mental fitness of probationers being considered for the Detention Center and Probation Boot Camp programs. The form collects detailed health history information and conducts observational assessments to identify any medical conditions that may affect program participation. While having a medical condition does not automatically disqualify candidates, this information helps staff make informed decisions about suitability and ensure appropriate medical support during the program. KEY_TOPICS: Medical screening, health history, boot camp eligibility, detention center admission, physical fitness assessment, mental health screening, medical conditions, seizures, diabetes, asthma, heart problems, tuberculosis, HIV testing, substance withdrawal, suicide risk, medication allergies ATTACHMENTS: 1. Sample Sentence Language for Probation Boot Camp URL: https://gps.press/sop-data/210.03-att-1/ 2. Special Conditions - Probation Boot Camp (Sample Court Order) URL: https://gps.press/sop-data/210.03-att-2/ 3. Medical Checklist for Screening Prospective Participants in the Detention Center and Probation Boot Camp Program URL: https://gps.press/sop-data/210.03-att-3/ 4. Probation Boot Camp Pre-Admission Orientation Form URL: https://gps.press/sop-data/210.03-att-4/ ======================================================================== FULL TEXT: ======================================================================== SOP IIB12-0003 (210.03) Attachment 3 07/15/15 **MEDICAL CHECKLIST FOR SCREENING** **PROSPECTIVE PARTICIPANTS IN THE DETENTION CENTER** **AND PROBATION BOOT CAMP PROGRAM** **Offender's Name:_____________________________________________________** **Social Security Number: _______________________________________________** **Date of Birth:_________________________________________________________** **Instructions** **This document is applicable to both the Probation Detention Center and Probation Boot** **Camp programs. The purpose of the document is slightly different when applied to the** **individual program.** **For Detention Centers, use of pages 2 and 3 is all that is necessary. It is very helpful for the** **Center to be alerted to any serious medical problems prior to the arrival of the probationer.** **Georgia law (42-8-35.1) gives the department the authority to determine if the probationer is** **physically and mentally suitable for the Boot Camp program. Therefore, it may be necessary** **and helpful to complete all relevant sections of the form so that an appropriate decision can be** **made. NOTE: Having one of the medical problems identified does not necessarily disqualify** **a probationer from Boot Camp participation.** **If any candidate for Detention Center or Boot Camp has a known significant health problem,** **this information should be shared at the time of referral. Please remember that in the Boot** **Camp program, the candidate may be rejected if found to be physically or mentally unfit for** **the program.** **The medical staff at the Detention Center and Boot Camp may be contacted for assistance.** **Page 1 of 8** **PART I - PARTICIPANTS HEALTH HISTORY** **In the past or present does the candidate have a history of any of the following:** **Condition** **Yes** **No** **Comments** **1.** **Diabetes** **___ ___ __________** **2.** **Epilepsy/Seizures ___** **___** **__________** **3.** **Kidney Disease** ___ ___ __________ **4.** **Hypertension (High Blood Pressure)** **___** **___ __________** **5.** **Heart Murmur/Heart Problems ___ ___ ___________** **6.** **Asthma/Chronic Bronchitis/Emphysema ___ ___ ___________** **7.** **Hepatitis** **___ ___ ___________** **8.** **Tuberculosis ___ ___ ___________** **9.** **Allergies, i.e., dust, trees, foods ___ ___ ___________** **10.** **Surgery** **___ ___ ___________** **11.** **Hearing Loss** **___ ___ __________** **12.** **Loss of Limb** **___ ___ __________** **13.** **Vision** **___ ___ __________** **14.** **Bone/Joint Defects** **___ ____ __________** **15.** **Back Problems** **___ ____ __________** **16.** **Psychological Problems** **___ ____ __________** **17.** **Special Diet** **___ ____ __________** **18.** **AIDS Test Result Positive ___ ____ __________** **19.** **Hospitalized for medical or psychiatric** **treatment in the past six months? For** **what reason? ____ ____ _________** **20.** **Any significant observations regarding** **physical or mental health of the probationer? ____ ____ _________** **Page 2 of 8** **PART II - INTERVIEWER OBSERVATIONS & MISCELLANEOUS INFORMATION** **Question** **Yes** **No** **Comments** **1.** **Does the candidate wear eye glasses or ___ ___ __________** **contact lens?** **(If accepted into the program, he must** **bring his glasses and/or contact lens** **with him.)** **2.** **Does he exhibit any visible signs of** **trauma, illness, limp, pain, limita-** **tions, or movement? ___ ___ __________** **3.** **Does he exhibit any signs of drug or** **alcohol withdrawal? ___ ___ __________** **4.** **Does he exhibit any signs of emotional** **disorders, excessive depression, or** **incoherent? ___ ___ ___________** **5.** **Does he exhibit any symptoms or need** **for immediate medical or dental care? ___ ___ ___________** **6.** **Does he have any allergies to** **medications? Which medications? ____ ____ _________** **If he is unsure, he should check with** **his family.** **7.** **Has this person attempted suicide in the past?** **____** **____ __________** **Page 3 of 8** **ATTACHMENT I** **ADDITIONAL QUESTIONS TO ASK FOR "YES" RESPONSES** **PART I** **(If any of the following questions are answered "yes" or if you have additional questions or** **concerns that need a medical opinion, you should call the medical staff at the center for** **assistance in determining suitability for admission.)** **1.** **Diabetes:** **Is the candidate insulin dependent?** **Is the candidate not stable on an oral hypoglycemic medication?** **2.** **Epilepsy/Seizure (fits, seizures): (If there has been a history of seizure but not one** **within the last year and the candidate is not on medication, he is eligible for the** **program.)** **Has the candidate had a seizure in the last year? Cause of seizure?** **Is the candidate taking medication for this disorder at the present time?** **Is the candidate under the care of a physician at the present time?** **3.** **Kidney Disease:** **Does the candidate have a history of glomerulonephritis or protein in the urine?** **Does the candidate have a history of acute or chronic kidney failure?** **Page 4 of 8** **Does the candidate have a history of ureteral stone (kidney stones)?** **4.** **Hypertension:** **Is the candidate taking medication?** **What medication?** **5.** **Heart Murmur/Heart Problems:** **What type of heart murmur or heart problem exists?** **Is the candidate currently taking medication?** **6.** **Asthma/Chronic Bronchitis/Emphysema:** **How long has the candidate had this condition?** **What are the limitations of activity?** **What medications is he taking?** **7.** **Hepatitis:** **When did he have hepatitis?** **Was it hepatitis A, B, or non-A, non-B? (Any past or current history of hepatitis** **requires a blood test to determine the type of hepatitis.)** **Is he still under a physician's care for hepatitis?** **Page 5 of 8** **8.** **Tuberculosis:** **How long has this condition existed?** **What medications is he taking for it?** **What were the results of the chest x-ray?** **Is the candidate taking INH medication for a positive PPD?** **9.** **Allergies, e.g., dust, trees, grasses, foods, grease, etc.:** **What allergies do you have?** **What do you do when you have a "bad" allergy?** **What medications do you take for allergies? (The need for a special diet would not** **prohibit a candidate from being eligible for the program. The institution, however,** **does need to know this information prior to his arrival.)** **Are there any restrictions regarding environment or activity because of the allergies?** **What are they? (The "key" is whether they are related to activities in which the** **candidate would be participating and whether they are under a physician's care.)** **Page 6 of 8** **10.** **Surgery:** **Any previous surgery that would prohibit strenuous activity? Which activities? When** **was the surgery performed?** **11.** **Hearing Loss:** **Do you have a hearing loss in both ears that requires constant use of hearing aids?** **(The key is constant use of hearing aids. If they were lost or forgotten, the person** **could be endangered.)** **12.** **Loss of Limb:** **Has there been the loss of any limb which would prohibit doing strenuous activity, i.e.,** **assigned details? Which activities?** **13.** **Vision: (Note: If they wear glasses or contacts, they must bring them when they enter** **the program.)** **Any vision worse than 20/50 in both eyes and/or not corrected by glasses. (If you have** **any questions, call the medical unit in the boot camp.)** **14.** **Bones/Joint Defects:** **Any current or past problems which would prohibit strenuous activity, i.e. assigned** **details? Which activities?** **15.** **Back Problems:** **Any current or past problems which would prohibit strenuous activity, i.e., assigned** **details? Which activities?** **Page 7 of 8** **Is or was he under a physician's care for the back problems? (If he is or was not under** **a physician's care, consider him eligible for the program.)** **15.** **Psychological Problems:** **Past hospitalization? Reason? When? For how long?** **Is he currently under treatment for a mental problem? What problem? Where is he** **being treated?** **Is he currently taking medication? If so, what medications?** **Is or has the candidate been treated for alcohol or drug abuse? When? Where?** **(Consider the length of time in jail because if they have been in jail for 30 days or** **more, they may have dried out in jail.)** **Was the candidate ever in a special class in grammar, middle, or high school? If so,** **what kind of special class and for what reason?** **17.** **Special Diet: (It would be a rare occasion in which need for a special diet could** **eliminate a candidate from being eligible for the program. This information is needed** **prior to the candidate's arrival at the center and the center will be so notified when** **this checklist is sent to the receiving center prior to the candidate's arrival as** **required.)** **Page 8 of 8** **Any medical or dental reasons which would require a special diet? What reason for** **the diet? What type of special diet? How long will he need to be on this diet?** **18.** **Positive AIDS Test Results: (Positive test does not necessarily eliminate a boot camp** **candidate, but need to determine if the person is actually ill at this time.)** **19.** **Hospitalization: (The purpose of this question is to determine if there were** **hospitalizations that the candidate may not have thought of in the context of the other** **questions.)** **Has the candidate been hospitalized for medical or psychiatric treatment in the past** **six months? Describe reason for hospitalization and the length of time hospitalized.** **RETENTION SCHEDULE:** **Upon completion of this form, it will be placed in the inmate/probationer's case history** **file.**