SOP_NUMBER: 508.03-att-1
TITLE: Offender Death Notification Form
REFERENCE_CODE: VG03-0001
DIVISION: Office of Health Services
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2020-07-13
WORD_COUNT: 176
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/265727
URL: https://gps.press/sop-data/508.03-att-1/

SUMMARY:
This form is used by facility mental health staff to document and report the death of an incarcerated individual to the Office of Health Services within 48 hours. The form collects information about the deceased offender, circumstances of death, mental health history, medical diagnoses, medications, and treatment contacts. Completed forms are submitted via fax and become part of the offender's permanent mental health file, which is retained for 10 years.

KEY_TOPICS: offender death notification, death reporting, mortality review, mental health documentation, cause of death, psychiatric history, psychotropic medications, suicide prevention, inmate death, facility reporting

ATTACHMENTS:
  1. Offender Death Notification Form
     URL: https://gps.press/sop-data/508.03-att-1/
  2. Offender Critical Incident Notification Form
     URL: https://gps.press/sop-data/508.03-att-2/

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FULL TEXT:
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SOP 508.03
Attachment 1

7/13/20


GEORGIA DEPARTMENT OF CORRECTIONS Name:________________________________________


**Offender Death Notification Form** ID#:__________________________________________


Facility:____________________________________ DOB:_________________________________________


Date:______________ Time:___________________ Race:_________________ Sex:____________________
**************************************************************************************************
This Offender Death Notification form must be completed by the facility mental health staff and FAXED to Office of
Health Services (478-992-5865) within 48 hours following the offender's death.
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**Information Concerning the Death:**

Date of Death: ____/_____/_____ Location:_________________________________________________________

Manner of Death: [  ] Hanging [  ] Exsanguination [  ] Overdose Suspected [  ] Homicide

Place of Death: [  ] GP  [  ] Isolation/Segregation [  ] SLU  [  ] Infirmary  [  ] CSU/ACU/Observation Cell

[  ] Other _________________________________________

Mental Health Level of Care: __________   Mental Health Diagnosis:_________________________________________

Medical Diagnosis/conditions:_________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Psychotropic Medication(s):___________________________________________________________________________

__________________________________________________________________________________________________

Medication Adherence:_______________________________________________________________________________

Last three (3) Mental Health Counselor Contacts:__________________________________________________________

Last three (3) Psychiatric Contacts:_____________________________________________________________________

**An Institutional Mental Health Mortality Peer Review panel has been scheduled to meet on ______/_______/_____**

Comments:________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature__________________________________ Completed on ______/_____/______ Faxed on _____/_____/_____


Form no. M03-01-01

Retention Schedule: Once completed, the original shall be placed in the offender’s mental health file (section 1). At the end of the offender’s need for mental health
services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.