SOP_NUMBER: 508.03-att-2
TITLE: Offender Critical Incident Notification Form
REFERENCE_CODE: VG03-0001
DIVISION: Health Services
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2020-07-13
WORD_COUNT: 202
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/265735
URL: https://gps.press/sop-data/508.03-att-2/

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

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 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.