SOP 508.28-att-2: Offender Critical Incident Notification Form
Summary
Key Topics
- critical incident notification
- serious self-injury
- attempted homicide
- exsanguination
- hanging attempt
- overdose
- mental health crisis
- CSU
- ACU
- safe cell
- peer review
- incident reporting
- self-harm
- mental health emergency
- offender safety
Full Text
SOP 508.28
Attachment 2
8/12/19
GEORGIA DEPARTMENT OF CORRECTIONS Name:
Offender Critical Incident Notification Form ID#:
Facility: DOB:
Date: Time: Race: Sex:
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This Offender Critical Incident Notification form must be completed by the facility MH staff and FAXED to Office of
Health Services (478-992-5865) within 48 hours following the offender's critical incident.
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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 Level of Care: MH Diagnosis:
Medical Diagnosis/conditions:
Psychotropic Medication(s):
Medication Adherence:
Last three (3) MH 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 / /
M03-01-02 (rev. 3/16) DO NOT WRITE ON BACK
Retention Schedule: Upon completion, once faxed to OHS the form shall be maintained in the mental health area for 10 years.