DJJ Form ADSD-005 "Protective Action Response Incident Report" - Florida

What Is DJJ Form ADSD-005?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 23, 2008;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form ADSD-005 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form ADSD-005 "Protective Action Response Incident Report" - Florida

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ADSD-005
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
P
A
RESPONSE INCIDENT R
ROTECTIVE
CTION
EPORT
: ______/______/______
DATE COMPLETED
month
day
year
SECTION ONE
Facility/Program/Unit: _______________________________________________________________________________
Please, no abbreviations.
Youth's Name: _______________________________________________________ Birth Date: ______/______/______
last / first
month
day
year
Age: __________ Race: ______________ Sex: ________ Height: _______________ Weight: ______________
SECTION TWO
Date of Incident: ______/______/______ Time of Incident: ___________ a.m. / p.m. (Circle one.)
month
day
year
Print the Names & Titles of All Staff Members
Print the Names & Titles of Other Staff Members &
Who Were Engaged With the Youth During the
Names & Identities of Non-Staff Members
(youths, parents, etc.) Who Observed the Incident
Incident (Including the Lead Staff Member)
1. ____________________________________________
1. _______________________________________________
2. ____________________________________________
2. _______________________________________________
3. ____________________________________________
3. _______________________________________________
4. ____________________________________________
4. _______________________________________________
5. ____________________________________________
5. _______________________________________________
6. ____________________________________________
6. _______________________________________________
SECTION THREE
(a) The lead staff member (person initiating the intervention) and each other staff member engaged with the
youth, as listed above in the left-hand column, shall give a complete explanation of what occurred, using the
guidelines provided on the page entitled, “Continuation Sheet – Explanation of Incident.”
q Yes
q No
(b) Were mechanical restraints used?
If “Yes,” attach the Mechanical Restraints
Supervision Log.
(c) After asking those involved in the incident, were any injuries reported or observed as a result of the type of
q Yes
q No
response used?
If “Yes,” please explain. Include names and titles. ________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PAR Incident Report
Page 1 of 4
Revised 6/23/2008
ADSD-005
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
P
A
RESPONSE INCIDENT R
ROTECTIVE
CTION
EPORT
: ______/______/______
DATE COMPLETED
month
day
year
SECTION ONE
Facility/Program/Unit: _______________________________________________________________________________
Please, no abbreviations.
Youth's Name: _______________________________________________________ Birth Date: ______/______/______
last / first
month
day
year
Age: __________ Race: ______________ Sex: ________ Height: _______________ Weight: ______________
SECTION TWO
Date of Incident: ______/______/______ Time of Incident: ___________ a.m. / p.m. (Circle one.)
month
day
year
Print the Names & Titles of All Staff Members
Print the Names & Titles of Other Staff Members &
Who Were Engaged With the Youth During the
Names & Identities of Non-Staff Members
(youths, parents, etc.) Who Observed the Incident
Incident (Including the Lead Staff Member)
1. ____________________________________________
1. _______________________________________________
2. ____________________________________________
2. _______________________________________________
3. ____________________________________________
3. _______________________________________________
4. ____________________________________________
4. _______________________________________________
5. ____________________________________________
5. _______________________________________________
6. ____________________________________________
6. _______________________________________________
SECTION THREE
(a) The lead staff member (person initiating the intervention) and each other staff member engaged with the
youth, as listed above in the left-hand column, shall give a complete explanation of what occurred, using the
guidelines provided on the page entitled, “Continuation Sheet – Explanation of Incident.”
q Yes
q No
(b) Were mechanical restraints used?
If “Yes,” attach the Mechanical Restraints
Supervision Log.
(c) After asking those involved in the incident, were any injuries reported or observed as a result of the type of
q Yes
q No
response used?
If “Yes,” please explain. Include names and titles. ________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PAR Incident Report
Page 1 of 4
Revised 6/23/2008
SECTION FOUR
(a) Lead Staff Member (Person Who Initiated Intervention)
Name / Title _____________________________________________________________________________________
Signature_____________________________________________ Telephone (_______) ________________________
(b) Supervisor/Acting Supervisor on Duty at Time of Incident:
I have reviewed this report. Date ____/____/____
month
day
year
Name / Title ________________________________________________ Signature_____________________________
Comments: (If additional space is needed, use the page entitled, “Continuation Sheet – Other Pertinent Information.”)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
(c) PAR Instructor or PAR Certified Supervisory Staff Person:
I have reviewed this report.
Date ____/____/____
Signature___________________________________________
month
day
year
Name / Title______________________________________________________________________________________
1. The use of the physical intervention techniques and/or mechanical restraints was in compliance with PAR policy
q Yes
q No
and the PAR training curriculum.
If you answered “no,” explain why.
Comments: (If additional space is needed, use the page entitled, “Continuation Sheet – Other Pertinent Information.”)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
(d) Post PAR Interview - Administrator/Designee: (NOTE: Completion of this section is not required if the staff
member completing the PAR Report is a Juvenile Probation Officer (JPO), Senior JPO, or a JPO Supervisor.)
q Yes
q No
1. I have interviewed the youth within the 30-minute time frame. A Medical Review is necessary.
Name / Title ___________________________________________________________________ Date ____/____/____
month
day
year
Signature__________________________________________________Telephone (_______) ____________________
Post PAR Interview Comments:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________________
(e) Administrator/Designee: I have reviewed this report.
Date _____/_____/_____
month
day
year
Name / Title ________________________________________________ Signature_____________________________
Comments/Corrective Action Taken by Administrator _____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PAR Incident Report
Page 2 of 4
Revised 6/23/2008
CONTINUATION SHEET: Explanation of Incident
INSTRUCTIONS: The lead staff member and each other staff member engaged with the youth must use this
sheet to completely explain what occurred. This includes, but is not limited to, explaining who, what, when,
where, and how of the Nature of the Action identified below and identifying the name(s) of the specific
techniques used. The names and titles of staff members and names and identities of observers should correspond
with those identified in Section Two.
Provide the data requested below. After explaining what occurred during the incident, print your name, sign, and
date at the bottom. If the space on this page i s insufficient for your explanation, make additional copies of this
sheet to continue. Print your name, sign, and date the bottom of any additional copies that are made as well.
Nature of the Action
Type of Response Used (Check all that apply.)
(Check all that apply.)
q
q
Verbal Intervention
q
q
Injury
Takedown
Handcuffs
q
q
Touch Technique
Damage
q
q
Soft Restraints
Waist Chains
q
q
Escape
Countermove
q
q
q
Restraint Belt
Leg Cuffs
Serious Disruption
q
Control Technique
Date of Incident: ____/____/____
Facility/Program/Unit: _________________________________________________
Please, no abbreviations.
Youth's Name: _______________________________________________________ Birth Date: ______/______/______
last / first
month
day
year
Age: ____________ Race: _________________ Sex: ________ Height: _______________ Weight: ______________
____________________________________
_____/_____/_____
________________________________
Staff’s Printed Name
month
day
year
Signature
PAR Incident Report
Page 3 of 4
Revised 6/23/2008
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CONTINUATION SHEET: Other Pertinent Information
INSTRUCTIONS: Use this sheet to provide additional information for any section other than Section 3(a).
Date of Incident: ____/____/____
Facility/Program/Unit: _________________________________________________
Please, no abbreviations.
Youth's Name: _______________________________________________________ Birth Date: ______/______/______
last / first
month
day
year
Age: ____________ Race: _________________ Sex: ________ Height: _______________ Weight: ______________
____________________________________
_____/_____/_____
________________________________
Staff’s Printed Name
month
day
year
Signature
PAR Incident Report
Page 4 of 4
Revised 6/23/2008
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