SOP_NUMBER: 508.28-att-2
TITLE: Offender Critical Incident Notification Form
DIVISION: Office of Health Services
TOPIC_AREA: 508 Policy-MH Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2019-08-12
WORD_COUNT: 174
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/607058
URL: https://gps.press/sop-data/508.28-att-2/

SUMMARY:
This form is used by facility mental health staff to document and report critical incidents involving offenders, such as attempted homicide, serious self-injury, or near-death overdoses. The completed form must be faxed to the Office of Health Services within 48 hours of the incident and includes information about the offender's mental health status, medical conditions, medications, and psychiatric contacts. The form initiates an institutional mental health critical peer review panel meeting.

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

ATTACHMENTS:
  1. Certificate of Approval for Crisis Stabilization Unit (CSU), Acute Care Unit (ACU), and Observation Cells
     URL: https://gps.press/sop-data/508.28-att-1/
  2. Offender Critical Incident Notification Form
     URL: https://gps.press/sop-data/508.28-att-2/
  3. Observation Cell Log
     URL: https://gps.press/sop-data/508.28-att-3/
  4. Suicide/Self-Injurious/Assaultive Behavior Information Form
     URL: https://gps.press/sop-data/508.28-att-4/
  5. Observation Cell Notification (Form M68-01-05)
     URL: https://gps.press/sop-data/508.28-att-5/
  6. Cell Analysis Form (M68-01-10)
     URL: https://gps.press/sop-data/508.28-att-6/

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FULL TEXT:
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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:
**************************************************************************************************
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.
**************************************************************************************************
**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.