SOP 508.03-att-2: Offender Critical Incident Notification Form

Division:
Health Services
Effective Date:
July 13, 2020
Reference Code:
VG03-0001
Topic Area:
508 Policy-MH Administration/Staff/Certification
PowerDMS:
View on PowerDMS
Length:
202 words

Summary

This form is used by mental health/mental retardation (MH/MR) staff to document and report critical incidents involving offenders, including attempted homicides, serious self-injuries, and near-death overdoses. The completed form must be faxed to the Office of Health Services within 48 hours of the incident and includes offender information, incident details, mental health history, medications, and documentation of institutional peer review scheduling. The form becomes part of the offender's permanent mental health file and is retained for 10 years.

Key Topics

  • critical incident notification
  • offender death
  • self-injury
  • attempted homicide
  • overdose
  • mental health incident reporting
  • MH/MR staff documentation
  • peer review
  • serious injury
  • hanging attempt
  • self-harm
  • exsanguination
  • medical incident form

Full Text

SOP 508.03
Attachment 2

7/13/20

GEORGIA DEPARTMENT OF CORRECTIONS Name:_____________________________________

Offender Critical Incident Notification Form ID #:_______________________________________

Facility:_____________________________________ DOB:______________________________________

Date:________________ Time:_________________ Race:_____________ Sex:_________________
*********************
This Offender Death Notification form must be completed by the facility MH/MR staff and FAXED to Office of
Health Services (478-992-5865) within 48 hours following the offender’s critical incident.
*********************
Information Concerning the Critical Incident:
Date of Critical Incident: ____/____/_____ Location:_________________________________________________

Type of Critical Incident : [ ] Attempted Homicide [ ] Serious Self-Injury type (more than one type can be checked):

[ ] Exsanguination (bleeding out) [ ] Cutting [ ] Hanging Attempt [ ] Near Death Overdose (Suspected) [ ] Accidental

[ ] Other (state type: ___________________________________________________________________________)

Place of Critical Incident:[ ] GP [ ] Isolation/Segregation [ ] SLU [ ] Infirmary [ ] CSU/ACU/Safe Cell [ ] Other

MH/MR Level of Care:_____________ MH/MR Diagnosis:_________________________________________

Medical Diagnosis/conditions:_____________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Psychotropic Medications:________________________________________________________________________

_____________________________________________________________________________________________

Medication Adherence:__________________________________________________________________________

Last three (3) MH/MR Counselor Contacts:__________________________________________________________

Last three (3) Psychiatric Contacts:_________________________________________________________________

Institutional MH Critical Peer Review panel has been scheduled to meet on _____/______/_______

Additional Comments:___________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Signature_________________________________ Completed on ____/____/____ Faxed on ____/____/____

Form no. M03-01-02

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.

Attachments (2)

  1. Offender Death Notification Form (176 words)
  2. Offender Critical Incident Notification Form (202 words)
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