SOP 508.28-att-4: Suicide/Self-Injurious/Assaultive Behavior Information Form
Summary
Key Topics
- suicide prevention
- self-injurious behavior
- self-harm
- assaultive behavior
- incident reporting
- mental health incidents
- CSU
- ACU
- risk factors
- severity assessment
- critical incident
- behavioral documentation
- mental health assessment
Full Text
SOP 508.28
Attachment 4
8/12/19
# Suicide/Self-Injurious/Assaultive Behavior Information
Date of Report:_____________________
Offender Name:____________________________ GDC ID#:___________________
Facility:___________________________________ Mental Health Level:___________
Security Status:_______________ Date of Suicide/Self-Injury/Assault:_____________
DESCRIPTION: (of self injurious/assaultive behavior and injury):
________________________________________________________________________
________________________________________________________________________
RISK FACTORS: [ ] Injured self (2 or more times) within past 2 months
[ ] Was released from CSU, ACU, or Psychiatric Hospital Services within the
past 2 months.
[ ] Has been locked down for over a month
[ ] Has received 3 or more Disciplinary Reports (DRs) within the past month
SEVERITY : [ ] Mild (medically examined, no need for treatment)
(returned to cell)
[ ] Moderate (medically treated and released)
(transferred to a higher level of care)
[ ] Severe* (medically treated in infirmary/hospital)
(admitted to CSU or a Psychiatric Hospital)
*also complete a Critical Incident form – M03-01-02 – (508.03 Att 2)
EXPLANATION: Offender’s explanation of behavior:_________________________
______________________________________________________________________
_______________________________________________________________________
Factors contributing to this behavior: (i.e., clinical, stressors, antecedents, consequences):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
HOUSING: Where was the offender housed when they injured/assaulted self/others?
[ ] GP [ ] SLU [ ] ACU/CSU [ ] Iso/Seg.
[ ] Other:_______________________________________________________________
Where was the offender placed after injuring/assaulting self/others?
[ ] GP [ ] SLU [ ] ACU/CSU [ ] Iso/Seg.
[ ] Other:_______________________________________________________________
Signature of person completing form:________________________________ Date:___________________
Form no. M68-01-09 Page 1 of 1
Retention Schedule: Upon completion, this form shall be given to the Statewide Mental Health Director
(original) fax within 48 hours of the incident (24 hours for suicides), a copy shall be placed in the
offender’s mental health file (section 7), in Section 5 of the Medical record, and a copy should be kept by
the MH Unit Manager. 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.