Incident Report Juvenile Corrections Center

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INCIDENT REPORT
JUVENILE CORRECTIONS CENTER–LEWISTON
A) Name of subject of report:
Cottage/group or unit assignment:
B) Day:
Date:
Time of incident:
am/pm
Location of incident:
Report prepared by and title :
Witness(es):
C) Type of incident: Check all that apply to the subject of the report.
Juvenile injury/illness
Visitor, volunteer, or intern injury/illness
Staff injury/illness
(If this box is checked, staff need to complete separate incident report.
Supervisor will begin accident report. Incident & accident report both need to be sent to HR)
Assault (or attempt) on juvenile
Assault (or attempt) on staff
Escape (or attempt)
Property damage
Theft
Contraband; specify:
Other; specify:
Suicide threat/attempt; specify:
Self-harm/mutilation; specify:
D) Action Taken: Check all that apply.
Physical intervention
Physical restraint
Room Time
Time In: _____________am/pm Time Out:
am/pm
Mechanical restraint: Time in:
am/pm; Authorized by:
Time out:
am/pm
Self-Imposed (Juvenile) Separation; Time in: ___ am/pm; Time out: ____am/pm (attach logs)
Suicide precautions initiated: Level
; Time
am/pm; by
Persons notified: Full name and title/relationship to subject
MANDATORY CONTACTS: Persons to be notified of each incident.
, Security, Time:
, Clinic, Time:
am/pm
am/pm
DJC-175-02
Rev. 06/09/08

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