"Incident / Complaint Report Form" - Florida

Incident / Complaint Report Form is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

Form Details:

  • Released on December 1, 2011;
  • The latest edition currently provided by the Florida Department of Juvenile Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

ADVERTISEMENT
ADVERTISEMENT

Download "Incident / Complaint Report Form" - Florida

Download PDF

Fill PDF online

Rate (4.5 / 5) 65 votes
Page background image
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF INSPECTOR GENERAL
CENTRAL COMMUNICATIONS CENTER
Incident / Complaint Report Form
CCC Incident Number:
CCC Duty Officer:
Program Code:
Program Name:
Region:
Report Date:
Incident Date:
Report Time:
Incident Time:
Place of Occurrence:
(Specific Location)
PAR Restraint Involved:
Yes
No
Unknown
Was Staff PAR Certified:
Yes
No
Staff to Youth Ratio:
Youth
Staff
Was Internal Investigation Initiated?
Yes
No
Unknown
Incident Category:
Background Information:
Immediate Action Taken:
Page 1 of 8
Revised 5/3/10 Updated 12/1/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF INSPECTOR GENERAL
CENTRAL COMMUNICATIONS CENTER
Incident / Complaint Report Form
CCC Incident Number:
CCC Duty Officer:
Program Code:
Program Name:
Region:
Report Date:
Incident Date:
Report Time:
Incident Time:
Place of Occurrence:
(Specific Location)
PAR Restraint Involved:
Yes
No
Unknown
Was Staff PAR Certified:
Yes
No
Staff to Youth Ratio:
Youth
Staff
Was Internal Investigation Initiated?
Yes
No
Unknown
Incident Category:
Background Information:
Immediate Action Taken:
Page 1 of 8
Revised 5/3/10 Updated 12/1/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF INSPECTOR GENERAL
CENTRAL COMMUNICATIONS CENTER
I
/ C
NCIDENT
OMPLAINT REPORT FORM
Persons Involved:
Reporting Person:
Phone#:
(
)
ext.
Contact Person:
Phone#:
(
)
ext.
Name
Person Type (Staff,
Involvement Type
JJIS/SSN#
D.O.B.
Youth, LEO, Parent,
(Subject/Victim/
etc.)
Witness, etc.)
Agency Notified:
Agency Name:
Notified:
Contact Name:
Contact Date:
Contact Time:
Agency Name:
Notified:
Contact Name:
Contact Date:
Contact Time:
Agency Name:
Notified:
Contact Name:
Contact Date:
Contact Time:
Agency Name:
Notified:
Contact Name:
Contact Date:
Contact Time:
FSFN#:
Operator #:
Allegations Accepted: Yes
No
Page 2 of 8
Revised 5/3/10 Updated 12/1/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF INSPECTOR GENERAL
CENTRAL COMMUNICATIONS CENTER
I
/ C
NCIDENT
OMPLAINT REPORT FORM
Involved Youth Info:
Committing Offense(s):
Escapes
Did Youth Escape or Attempt to Escape?
Yes
No
Staff/Youth Ratio at Time of Escape:
to
Was Youth Apprehended:
Yes
No
Apprehended Date:
Apprehended Time:
Apprehended Location:
Apprehended By:
Was the youth previously identified as an escape risk?
Yes
No
If so, when and what actions were taken:
Additional information regarding the escape:
Home City Law Enforcement and County Notified?
Yes
No
Policy and/or contract requirements for Staff/Juvenile ratio:
to
Youth activities 12 hours prior to escape:
Was there property damage to the facility?
Yes
No
Description of the damage:
Has the damage been repaired?
Yes
No
Did any staff assist the youth?
Yes
No
Has the Facility taken steps to correct conditions that aided escape?
Yes
No
Explain what steps were taken:
Page 3 of 8
Revised 5/3/10 Updated 12/1/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF INSPECTOR GENERAL
CENTRAL COMMUNICATIONS CENTER
I
/ C
NCIDENT
OMPLAINT REPORT FORM
Medical
Was medical treatment provided?
Yes
No
Who treated the youth (nurse at facility, physician, hospital)?
When was the youth treated?
Date:
Time
Extent of Treatment:
When was the youth returned to facility?
Date:
Time
Was treatment initiated by sick call request or emergency care?
Yes
No
Was the youth admitted for outside treatment?
Yes
No
What is the diagnosis?
Was youth receiving treatment from the facility prior to the incident?
Yes
No
Provide a summary of youth's medical status since arriving in the facility:
Status and location of youth:
Baker Act
Was mental health treatment provided?
Yes
No
Who treated the youth (nurse at facility, physician, hospital):
When was the youth treated?
Date:
Time
Extent of Treatment:
Page 4 of 8
Revised 5/3/10 Updated 12/1/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
OFFICE OF INSPECTOR GENERAL
CENTRAL COMMUNICATIONS CENTER
I
/ C
NCIDENT
OMPLAINT REPORT FORM
Baker Act (continued)
Was youth committed pursuant to Baker Act?
Yes
No
If yes, who made the decision?
When was youth returned to facility?
Date:
Time
Is the youth currently prescribed psychotropic medication?
Yes
No
If yes, list name(s):
Any history of prior Baker Acts:
Yes
No
Number:
Was the youth admitted for outside treatment?
Yes
No
Was youth receiving treatment from the facility prior to the incident?
Yes
No
Provide a summary of youth's mental status since arriving in the facility:
What was the level of supervision for the youth at the facility?
Were there restrictions on the youth? (Specifics)
Status and Location of Youth:
Prior History Of Suicide Attempts?
Yes
No
Number:
(Review JJIS and determine based on alerts.)
When was the last Suicide Risk completed?
What was the Suicide Risk Recommendation?
When was the last MAYSI/PACT completed?
Were the recommendations followed?
Yes
No
Was the parent or legal guardian notified?
Yes
No
Page 5 of 8
Revised 5/3/10 Updated 12/1/11
Page of 8