Dd Form 2711 - Initial Custody Classification Page 2
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4CLASSIFICATION WORKSHEET
11. DATE (YYYYMMDD)
12. TIME
13. INTERVIEWER NAME (Last, First, Middle Initial)
14. (X one)
PRE-TRIAL
POST-TRIAL
15. IDENTIFICATION
a. PRISONER NAME (Last, First, Middle) (AKA)
b. REGISTRATION NUMBER c. GRADE
16. ADMINISTRATIVE FACTORS (X as applicable)
a. SUICIDE RISK
(1) HOW DO YOU FEEL ABOUT BEING HERE?
NO
YES
(2) HAVE YOU EVER THOUGHT ABOUT COMMITTING SUICIDE? (X one) (If Yes, when? (YYYYMMDD))
(3) DID YOU MAKE A PLAN TO COMMIT SUICIDE? (X one) (If Yes, when? (YYYYMMDD))
(4) HAVE YOU EVER ATTEMPTED SUICIDE? (If Yes, when (YYYYMMDD) and how?)
b. PHYSICAL HEALTH PROBLEM
NO
YES
(1) DO YOU HAVE A CONTAGIOUS DISEASE? (If Yes, what?)
(2) DO YOU HAVE ANY PHYSICAL PROBLEMS? (If Yes, what?)
(3) ARE YOU TAKING ANY MEDICATIONS? (If Yes, give reason)
c. MENTAL HEALTH
NO
YES
(1) DO YOU HAVE ANY MENTAL PROBLEMS? (If Yes, what?)
(2) WERE YOU EVER HOSPITALIZED FOR MENTAL PROBLEMS? (If Yes, when? (YYYYMMDD))
d. SPECIAL QUARTERS
NO
YES
TO YOUR KNOWLEDGE, DO YOU HAVE ANY ENEMIES IN THIS FACILITY? (If Yes, who and why?)
DD FORM 2711, MAR 2013
Page 2 of 4 Pages
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