SOP_NUMBER: 222.09-att-2 TITLE: Crisis Form REFERENCE_CODE: IIA02-0002 DIVISION: Facilities TOPIC_AREA: 222 Policy-Court/Release/Transport/Transfer EFFECTIVE_DATE: 2018-10-17 WORD_COUNT: 383 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/123078 URL: https://gps.press/sop-data/222.09-att-2/ SUMMARY: This form is used to document and process crisis situations involving incarcerated individuals, including deaths of family members or serious illnesses requiring potential temporary release or funeral attendance. Staff complete the form to gather initial contact information, coordinate with the Office of Victim Services, assess the offender's security risk and institutional behavior, and obtain recommendations from chaplains, counselors, and wardens regarding any requested reprieve or temporary release. The form ensures victim services are notified and all relevant information is documented in the offender's institutional file. KEY_TOPICS: crisis form, death notification, funeral attendance, temporary release, reprieve, parole board, victim services, family emergency, chaplain, counselor, security risk assessment, institutional behavior, emergency contact ATTACHMENTS: 1. Compassionate Visit Form URL: https://gps.press/sop-data/222.09-att-1/ 2. Crisis Form URL: https://gps.press/sop-data/222.09-att-2/ ======================================================================== FULL TEXT: ======================================================================== 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.