SOP_NUMBER: 508.28-att-4
TITLE: Suicide/Self-Injurious/Assaultive Behavior Information Form
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy - MH Suicide Prevention/ACU/CSU/BTU
EFFECTIVE_DATE: 2019-08-12
WORD_COUNT: 274
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/440981
URL: https://gps.press/sop-data/508.28-att-4/

SUMMARY:
This is a required incident reporting form (M68-01-09) used to document and analyze cases where an offender engages in suicide attempts, self-injurious behavior, or assaultive behavior. Staff must complete the form to record details about the incident, identify risk factors, assess severity, and document contributing factors. The form must be submitted to the Statewide Mental Health Director within 24-48 hours depending on incident type, with copies placed in the offender's mental health and medical files.

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

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 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.