SOP 222.09-att-2: Crisis Form

SOP 222.09
Attachment 2
10/17/18
Page 1 of 2

___________________________________
Facility
CRISIS FORM

PART I: INITIAL CONTACT INFORMATION
1. Date ______________________________Time: ____________________Shift: ______________
2. Name of Staff Member Taking Information: _____________________________________________
3. Name of Chaplain/Counselor: _______________________________________________________
4. Offender’s Name: ________________________________I.D. #: __________________ Dorm: ____
5. Detail: __________________________________________________________________
6. Name of Deceased/Ill: _______________________________________Phone #____: ___________
7. Address: ______________________________City: ______________State: _______Zip: _________
8. Relationship to Offender: ________________________Nature of Crisis: _____________________
9. Name of Person Contacting Facility: _____________________________Phone #: _ _____________
10. Address: ______________________________City: ______________State: ______Zip: __________
11. Relationship to Offender: ____________________________________________________________

IN CASES OF DEATH:
12. Funeral Home: ___________________________________Phone #: _________________________
13. Address: ______________________________City: _____________State: ______Zip__________
14. Location of Funeral: _______________________________Date: ___________Time: _____________

TRANSPORTATION TO FUNERAL:
15. Sheriff's Department: ____________________________Contact: ______________Ph.: ___________
16. Address: _____________________________City: ____________State: _________Zip: ___________

IN CASES OF ILLNESS/HOSPITAL:
17. Hospital: ________________________________________Phone #: _________________________
18. Doctor's Name: ___________________________________Phone #: _________________________
IF AFTER 4:30 P.M.:
19. Duty Officer Notified__________: _______________________Date: ____________Time: ________

VICTIM SERVICES: SHALL BE CONTACTED AT THIS POINT.
(See Attachment 3, The Office of Victim Services Critical Contact List)

20. Designee Contacted: ___________________________ Date: __________________ Time: __________
21. Contacted by (Printed Name/Title): _________________Email ________________ Phone #_________
22. Recommendation: Support: _____ Oppose: ____ See Attached Email from Victim Services.

Comments: _______________________________________________________________________________

________________________________________________________________________________

NOTE: ALL INFORMATION FROM VICTIM SERVICES, SHALL BE CONFIDENTIAL

Retention Schedule: Upon completion, this form shall be sent to the Office of Victim Services and made a permanent and confidential
part of the Office of Victim Services’ file. A copy of this form shall be placed in offender’s institutional file.

SOP 222.09
Attachment 2
10/17/18
Page 2 of 2

PART II: CONTACT WITH OFFENDER AND FAMILY
1. Offender Seen by Chaplain/Counselor: __________________________Date: ________Time: _______
2. Emotional State: _ __________________________________________________________________
3. Family Contacted by Chaplain/Counselor: ________________________Date: ________Time: _____
4. Family Informed of Procedure Requesting:
a. Reprieve from Parole Board: __________________________ Sheriff's Escort: _____________
5. Name of Family Member Informed: _____________________________Phone #: _ _____________
6. Address: ______________________________City: __________State: __________Zip: ____________

PART III: INFORMATION FROM FILE
1. Relationship of Ill/Deceased Verified: ____________________________________________________
2. Security of Offender: Close _________ Medium ___________ Minimum ___________
3. Offender on Mental Health? Yes____ No____
4. Medication: _________________________________________________________________________
5. Nature of Offense: ____________________________________________________________________
___________________________________________________________________________________
a. Past Violent Offenses/Sex Offenses: ____________________________________________________
___________________________________________________________________________________
6. Length of Sentence: ______________________ TPM or MAX Release Date: ____________________
7. Institution Behavior: (Escape, Detainer, D.R., Attitude, Work Performance) ______________________
___________________________________________________________________________________

PART IV: RECOMMENDATIONS
1. Chaplain’s/Counselor's Recommendation:
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________
Signature

2. Deputy Warden of Care and Treatment/Chief Counselor/ Senior Counselor Recommendation:
___________________________________________________________________________________
___________________________________________________________________________________
_________________________________________
Signature

3. Deputy Warden of Security/Assistant Superintendent Recommendation:
___________________________________________________________________________________
___________________________________________________________________________________
_________________________________________
Signature

4. Warden/Superintendent needs additional information before making decision? Yes_______ No______
If yes, state information needed: ________________________________________________________

5. Warden's/Superintendent's Decision: ____________________________________________________
__________________________________________________________________________________
________________________________________
Signature

Retention Schedule: Upon completion, this form shall be sent to the Office of Victim Services and made a permanent and confidential
part of the Office of Victim Services’ file. A copy of this form shall be placed in offender’s institutional file.