Incident Report
Reference Guide
2010
Prepared by the State of Utah, Division of Juvenile Justice Services
Office of Internal Investigations
Revised October 22, 2009
INTRODUCTION
Critical incidents occur within all programs and facilities under the direction of the Division of
Juvenile Justice Services (DJJS). These events range from situations as simple as “information
only” to others, which may require referrals to the respective county attorney’s office or law
enforcement.
These non-routine, unusual or potentially threatening circumstances require proper
documentation. This documentation is accomplished by the preparation of Incident Reports.
This Reference Guide will explain:
 When to prepare an Incident Report
 Who should prepare an Incident Report
 How to prepare an Incident Report
 Who should be notified of an incident
 How Incident Reports are distributed
 Associate Program Director (APD) notification
 Overall incident Summary Log for each facility/program distribution
 How the Juvenile Court or entities other than DJJS are notified and/or distributed
Incident Reports
In the event you require an internal investigation contact any of the following investigators:
Tara Jorgenson - Director
Office of Internal Investigations
Ogden Regional Center
2540 Washington Blvd
Basement Rm.#26
Ogden, Utah 84401
(801) 514-2632 Cell
(801) 626-3407 Fax
tjorgens@utah.gov
Jantz Afuvai
Internal Investigator
(801) 626-3397 Office
(801) 514-2353 Cell
(801) 626-3407 Fax
jafuvai@utah.gov
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Dustin Howard
Internal Investigator
(801) 626-3396 Office
(801 514-0728 Cell
(801) 626-3407 Fax
dustinhoward@utah.gov
DIRECTIONS FOR COMPLETING INCIDENT
REPORTS
An Incident Report shall be generated by staff to account for any non-routine, unusual, or
potentially threatening event or incident that occurs. The report shall be prepared generally by
staff, but may be used by any person having direct involvement in or knowledge of an incident.
When multiple staff respond to or have knowledge of an incident a lead person shall be
designated to generate an Incident Report per incident episode. All others shall generate
Supplemental Reports describing their involvement during and immediately after an incident.
An incident episode generally refers to the length of an incident at onset until the incident has
been dealt with or resolved.
In the event that an Incident or Supplemental Report has been signed and submitted and the
writer remembers or learns that additional information is needed or requested in writing, then
staff shall generate an Addendum Report. An Addendum Report shall be written using the
Supplemental Report format and its writer shall indicate in the Description of Incident portion of
the report that this report is an addendum to my original Incident (or Supplemental) Report,
while referring to the original Incident (or Supplemental) Report number.
All reports are considered to have been submitted after its writer has either signed the report; or
has sent the report via courier, fax, mail, or email (regardless of whether the report is signed).
Once a report has been submitted it is considered complete and will be used as an official
document accounting for the incident. Once reports have been submitted they shall not be
altered, modified, or amended. An Addendum Report however, may be used to document
additional information.
Incident, Supplemental, and Addendum Reports should be limited to factual, concise, and
objective information that accounts for what its writer did during and immediately after the
incident.
I. WHEN TO PREPARE AN INCIDENT REPORT.
Incident Reports should be used to describe any non-routine, unusual, or potentially
threatening event in a DJJS facility or program, or contracted private provider when the
event involves DJJS. Events requiring completion of an incident report include, but are not
limited to: accidents, suicide attempts, assaults, physical interventions, absconded youth,
or any other non-routine, unusual, or potentially threatening occurrences. Reports shall be
completed before the end of the shift when the incident occurred, or within 24 hours
when approved by a supervisor. Incident Report forms do not replace other required
documentation (e.g. disciplinary and/or progress notes).
II. WHO SHOULD PREPARE AN INCIDENT REPORT.
Employees of the Division of Juvenile Justice Services, Private Providers contracted with
the Division, and any other person(s) having legitimate business with any youth under
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Division care shall prepare a report when incidents occur. Any person(s) involved in or
directly aware of an incident shall complete an Incident or Supplemental Report. A person
who may not have witnessed an incident, but may have received information about an
incident may also generate an Incident Report. There should only be one Incident Report
per incident episode. All other reports accounting for an incident shall be written in a
Supplemental Report format.
III. WHO SHOULD PREPARE A SUPPLEMENTAL REPORT.
Supplemental Reports are completed by staff (or witnesses) when more than one staff
responds to or is aware of an incident. One staff shall be appointed to generate an Incident
Report and all others shall generate Supplemental Reports. Again, there should only be
one Incident Report per incident episode.
IV. PREPARATION OF AN INCIDENT REPORT.
When preparing an Incident or Supplemental Report, all applicable portions of the Report
shall be completed. The following is a description of what information needs to be
included in each portion of the report:
A. Juveniles Involved: The names of all the juveniles involved should be listed
including their case number when available (Case # Last, First, Middle Name).
B. Date, Time & Incident Location: The date and time should reflect when the
incident occurred and not when the report was generated or completed. The
location of the incident should describe specifically where the incident occurred.
For example: If an incident occurred at the Mill Creek Youth Center (MCYC),
then the location should clarify specifically where in the MCYC the incident
occurred, e.g. Cottage W, Room 1.
C. Staff on Shift and Witnesses: The person preparing the report should list names
of staff members on shift who were involved in or have knowledge of the
incident. Witnesses include other youth, volunteers, school staff, or any person(s)
who witnessed the event.
D. Description of the Incident (Section A): The most critical portion of the report!
Information contained here should define who is preparing the report (name and
job title). All reports should be written in first person (for example: I, John Doe,
JJS Counselor II…). The information written should be clear, concise, accurate,
specific and as detailed as possible. The writer should always strive to report
objectively, factually, and as accurately as possible. Subjective and judgmental
statements should be avoided.
When incidents result in physical intervention by way of control holds and/or
mechanical restraints, the writer should document specifically which control holds
were used, who applied the restraints, and how long the holds and/or restraints
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were used. The writer should also document any verbal de-escalation techniques
that were used as well as their justification for using force in line with Division
policy. Again, clear, concise, specific, accurate, and detailed information are
the most important elements of this section.
E. Use of Force (Section B): Anytime force is used by staff during an incident, all
staff involved shall use the check boxes to identify their justification to use force
as governed by Division policy. Each staff shall also identify and document the
control hold (by name) that was attempted or applied to the youth. If the use of
force resulted in an injury (e.g. rug burn, bloody nose, etc.) to youth or staff then
the injury shall be documented in this section as well. The writer shall identify
who was injured, what was done about the injury, and whether medical attention
was required. Anytime medical attention is required, the person writing the report
will identify the medical personnel (by name) and the date that the person
received the medical attention.
F. Injury Accounting (Section C): Anytime an injury is observed or occurs then
staff shall document the injury and report it to their supervisor, medical personnel,
or emergency services depending on its severity. When an injury occurs as a
result of an incident (excluding injuries already accounted for during a use of
force type of incident covered in Section B) then this section is to be used to
account for when the injury was observed, how the injury was sustained, and what
was done about the injury.
G. Action Taken (Section D): The person who has prepared the report should list
what immediate action was taken or any further recommendations they deemed
appropriate. This section should also indicate who was informed of the incident,
e.g. the supervisor (by name) notified.
H. Attachments: In this section, the writer indicates that additional information is
included with the Incident Report. This additional information may include one or
more of the following:
1. Supplemental Report: This checkbox is marked in the event a
Supplemental Report has been prepared. Include the number of
Supplemental Reports completed.
2. Evidence. This check box is marked if some form of evidence has been
collected. This includes contraband, weapon, illegal substance, etc.
3. Diagram. This checkbox is marked when a diagram has been provided as
an attachment to the initial Incident Report, describing an area or
something significant about the incident.
4. Surveillance Camera. This checkbox is marked when the incident
occurred within the view of a facility/program surveillance camera.
5. Other. This checkbox is marked when any other attachments not
previously clarified are necessary. For example: photographs, letters,
drawings/writings, etc.
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I. Check Boxes: In this section, the writer indicates all boxes that apply to the
incident.
J. Classification. The writer identifies the type of incident and the Level (1-4) of
severity of the incident that took place.
K. Incident #: In order to provide for more efficient accounting of incident reports,
a number should be assigned to each report generated. This number is to be
assigned by secretarial or other designated office staff.
V. NOTIFICATION OF INCIDENT: All incidents (Level’s 1-4) shall be reported within
twenty-four (24) hours of occurrence. Depending upon the incident’s severity (Level 14), notification of an incident shall follow a Chain of Command as outlined near the end
of this reference guide. All parties within the Chain of Command, as dictated by the
incident’s severity, shall be notified as well. All Level 1 notifications shall be handled in
the following manner: Notification shall be done immediately by phone with a live
person. A voicemail message is not sufficient as notification for a Level 1 incident.
The person who is attempting to make contact with someone on the Chain of
Command shall start with their immediate supervisor and then proceed upward from
there. Private Providers shall contact the youth’s Case Manager first; if unsuccessful
the Private Provider shall contact an Investigator from the DJJS. Once a live person
has been contacted it is the responsibility of that contacted person to notify the next
person/party in the Chain of Command. All incident notification attempts and contacts
shall be documented in the Action Taken portion of an Incident or Supplement Report.
VI. DISTRIBUTION OF INCIDENT REPORT. An Incident or Supplemental Report(s)
shall be distributed to all parties listed under the Chain of Command as based on the
severity of the incident. Distribution may be done through email, fax, courier, or mail
depending on the situation (contact an Investigator if unsure). The original Incident and
Supplemental Report(s) shall be kept and maintained indefinitely by the sending facility
or program. The facility or program administration shall store all original reports.
Copies of the original Incident and Supplement Reports shall be sent to the youth’s Case
Manager when the incident involves a DJJS youth. When the incident did not involve,
implicate, or influence a DJJS youth, rather a staff on staff issue, etc. copies of the
original reports shall be sent to the appropriate party(s) within the Chain of Command
(this mainly applies to DJJS employees).
VII. ASSOCIATE PROGRAM DIRECTOR NOTIFICATION. (This only applies to DJJS)
All unusual incidents that endanger the lives or physical welfare of the youth or staff
shall be reported to the Associate Program Director or designee, immediately. Examples
of these types of incidents include, but are not limited to:




Death
Attempted suicide when hospitalization occurs
Fire, when serious bodily harm or significant building damage is done
Riot
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


Any assault on youth by a staff member
Sexual assaults, relations or indecent liberty
An escape from a correctional facility
VIII. DISTRIBUTION OF INCIDENT REPORT SUMMARY LOG: Facilities or programs
shall fax or email a copy of the Incident Report Summary Log to the Office of Research
Evaluation & Planning (REP) representative quarterly.
IX. JUVENILE COURT OR ENTITY OTHER THAN DJJS NOTIFICATION /
DISTRIBUTION: Notification that an incident occurred and the distribution of any
reports generated by DJJS to agencies or entities other than DJJS shall be dealt with by
the principal DJJS administrator where the incident occurred. Copy(s) of Incident or
Supplemental Report(s) may be forwarded to agencies or entities other than DJJS only
after the principal DJJS administrator has deemed it necessary for release. The principal
DJJS administrator may notify other agencies or entities of incidents that occur when the
incident pertains to the function of the other agency or entity. Incident and Supplemental
Reports are classified as “private” under the Governmental Records Access Management
Act (GRAMA, UCA 62-3-204). Incident and Supplemental Report(s) that are collected
during the course of an Internal Investigation become “protected” under GRAMA. In the
event that Incident and Supplemental Reports are deemed necessary for release to law
enforcement or a District or County Attorney’s Office, please contact an Investigator or
The Office of Quality Assurance for further release information.
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INCIDENT REPORT LEVELS OF SEVERITY
The Level of Severity system identifies the severity of the incident that occurs within the
facility/program.
The system is comprised of four levels of severity:
Level 1
Level 2
Level 3
Level 4
Maximum severity
Intermediate severity
Minimum severity
Information only
As indicated, the classification of incident reports delineates from the most severe to the least
severe.
Directions for completing Incident and Supplemental Reports have been distributed to all
programs and facilities throughout the DJJS and to all contracted private providers. The Incident
Report Reference Guide is also accessible through the policy and procedure section of the DJJS
website.
As a reminder, all Incident and Supplemental Reports shall be completed before the end of the
employee’s shift when the incident occurred, or within twenty-four (24) hours when approved
by a supervisor.
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INCIDENT REPORT LEVELS OF SEVERITY
LEVEL 1 – MAXIMUM SEVERITY
ACCIDENT
 Where the injury requires immediate treatment from a medical professional or hospital.
AGGRAVATED ASSAULT
 Assault with an object and serious bodily injury occur(s).
ARSON
ANY CRISIS EMERGENCY RESPONSE INVOLVEMENT FROM AN
AGENCY/ENTITY OUTSIDE THE DIVISION
 When an incident requires that a crisis emergency response type of agency/entity is
contacted or dispatched to take tactical command over the incident. A crisis emergency
response type of agency/entity includes, but is not limited to: Law Enforcement, Fire
Department, Centers for Disease Control (CDC), etc.
ANY SERIOUS BODILY INJURY OCCURS
 Means any bodily injury that creates or causes serious permanent disfigurement,
protracted (prolonged or extended) loss, or impairment of the function of any bodily
member, or organ, or creates a substantial risk of death;
 Whether intentionally or not.
ESCAPE
 By prisoner from a secure facility or detention center.
ILLNESS
 Where the illness requires immediate treatment from a medical professional or hospital.
OFFICIAL MISCONDUCT BY STAFF
 Any illicit drug activity by staff, youth, school employee, private provider or other;
 Any Code of Ethics or Policy & Procedure violations that endanger the lives or physical
welfare of staff or youth.
OTHER
PROPERTY DAMAGE
 With discretion, damage to a DJJS facility may result in 3rd Degree Felony charges
consistent §76-8-418; or the value of the property is or exceeds $5,000.
RIOT
 When two or more youth engage in tumultuous or violent conduct consistent with §76-9101.
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SUICIDE – COMPLETED
UNATTENDED OR ATTENDED DEATH
UNLAWFUL SEXUAL ACTIVITY WITH A YOUTH IN CUSTODY
 Custodial Sexual Relations
 Custodial Sexual Misconduct – Indecent Liberties
WEAPONS RELATED OFFENSES BY RESTRICTED PERSONS, OR ANY FIREARM
RELATED OFFENSE
 Category I Restricted Persons
 Any Parolee;
 Any youth convicted of a violent felony as defined in § 76-3-203.5;
 Remains Cat I Restricted Person for 10 years.

Category II Restricted Persons
 Any youth convicted of any felony;
 Remains Cat II Restricted Person for 7 years.
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LEVEL 2 – INTERMEDIATE SEVERITY
ABSCONDED FROM PLACEMENT
 Youth absconds from a community-based program (e.g. O&A, Genesis, proctor care,
group home, etc.);
 This only applies to adjudicated youth committed to DJJS for community placement.
ACCIDENT
 Where the injury requires treatment within 24 to 48 hours from a medical professional.
AIDING A RIOT
ANY PHYSICAL INTERVENTION AND/OR RESTRAINT USED
 Use of any physical intervention technique;
 Use of any mechanical restraint or device used for the purpose of restricting movement;
 Use of any chemical for the purpose of restraining a youth; or a chemical that could be
perceived as being used for the purpose of restraining a youth;
 DJJS justification for any physical intervention or restraint must be in compliance with
Policy No. 05-07.
ANY SUBSTANTIAL BODILY INJURY OCCURS
 Means bodily injury, not amounting to serious bodily injury, that creates or causes
protracted (prolonged or extended) physical pain, temporary disfigurement, or temporary
loss or impairment of the function of any bodily member or organ.
ASSAULT BY PRISONER WITH INJURY
 An assault by any youth incarcerated in a DJJS Detention Center or Secure Facility on
another person.
ATTEMPTED ESCAPE FROM A CORRECTION FACILITY
ASSAULT AND SUBSTANTIAL BODILY INJURY OCCURS
CODE OF ETHICS / POLICY & PROCEDURE VIOLATIONS OR PROVIDER CODE
OF CONDUCT VIOLATIONS
 Where a staff is sanctioned and/or terminated as a result of the violation.
CRIMINAL MISCHIEF
 Any person who intentionally and unlawfully tampers with property of another (or the
State) and by doing so recklessly endangers human life or human health or safety or
recklessly causes or threatens a substantial interruption or impairment of any critical
infrastructure; to include communication systems (e.g. radios, computers, DVR’s).
ILLNESS - PROLONGED
 When a person exhibits an illness over an extended period of time, has been seen by a
medical professional and their health does not appear to improve.
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LEWDNESS
 A person who performs any of the following acts in public; or the person should have
known that any of the following acts would likely be offensive, insulting or alarming:
 Expose genitals, female breast (areola), buttocks, anus, or pubic area;
 Masturbates.
MISCONDUCT REPEATED ACTIVITY
PROPERTY DAMAGE
 When the value of the property is or exceeds $1,000, but is less than $5,000.
OBSTRUCTING JUSTICE
 When a person hinders, delays, or prevents an investigation, apprehension, prosecution,
conviction, or punishment of any person;
 Harbors a youth who has absconded from the temporary custody of the Division.
OTHER
SUICIDE – ATTEMPT OR GESTURE
THEFT
 When the value of the property is or exceeds $1,000.
THREATS AGAINST LIFE OR PROPERTY
 A Terroristic Threat is made and is consistent with §76-5-107 of the Utah Criminal Code.
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LEVEL 3 – MINIMUM SEVERITY
ABSCONDED YOUTH
 Any non-adjudicated youth who absconds from a DJJS program with non-secure beds
(e.g. Receiving Centers, Youth Services, etc.);
 Any non-adjudicated youth who absconds from a DJJS program with non-secure beds,
that is placed with the DJJS program by another agency like the Division of Child and
Family Services; notification to the placing agency may apply.
ABUSE OF PSYCHOTOXIC CHEMICIAL SOLVENT
 Causing youth to become altered or ill
ASSAULT BY PRISONER NO INJURY
 An assault by any youth incarcerated in a DJJS Detention Center or Secure Facility on
another person where no injury was sustained.
ASSAULT WITH INJURY
 Injury sustained, but not amounting to serious or substantial bodily damage.
CODE OF ETHICS / POLICY & PROCEDURE VIOLATIONS OR PROVIDER CODE
OF CONDUCT VIOLATIONS
DISORDERLY CONDUCT
HARRASSMENT
GANG RELATED OFFENSES
 Throwing gang signs, gang writing not amounting to property damage or criminal
mischief.
GIVING A FALSE ALARM
OTHER
PROPERTY DAMAGE
 When the value of the property is less than $1,000.
PROVIDING CONTRABAND
 Defined as any merchandise, article, substance, or item prohibited or restricted in
Division programs and/or facilities due to programmatic restrictions or materials that are
illegal, unsafe, or potentially dangerous in nature. Contraband includes, but is not limited
to: tobacco, drugs, alcohol, weapons; devices capable of being used to affect an escape,
and expensive items, such as jewelry and money.
PROVIDING FALSE INFORMATION
Page 13 of 20
PROVIDING FALSE WRITTEN STATEMENTS
SEXUAL BATTERY
 A person who intentionally touches, whether or not through clothing, the anus, buttock,
or any part of the genitals of another person, or the breast of a female and the person
knows that the act is likely offensive, insulting, or alarming.
THEFT
 When the value of the property is less than $1,000.
Page 14 of 20
LEVEL 4 – INFORMATION ONLY
ANY ACCIDENT
 Even if no injury was sustained.
ANY INJURY
 All injuries need to be accounted for.
ANY POTENTIAL LITIGATION
 You are threatened or received notice of lawsuit.
ASSAULT – NO INJURY
BUILDING SAFETY ISSUES
CODE OF ETHICS / POLICY & PROCEDURE VIOLATIONS OR PROVIDER CODE
OF CONDUCT VIOLATIONS
CUSTODIAL INTERFERENCE
 Not amounting to Obstructing Justice
OTHER
POSSESSION OF CONTRABAND
 Dependent upon what is confiscated
TAMPERING WITH EVIDENCE
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CHAIN OF COMMAND
(For the Notification of incident’s and Distribution of Incident/Supplement Reports)
LEVEL 1
(MAXIMUM SEVERITY)
1.
2.
3.
4.
5.
6.
7.
DJJS Director, Dan Maldonado
Office of Internal Investigations *
Program Director (PD)
Associate Program Director (APD)
Supervisor
Case Manager *
Any other appropriate entity
All Level 1 notifications are to be done immediately by phone with a live person. Voicemail is
not sufficient! When available, a voicemail message shall be left at each level in pursuit of a
live person.
LEVEL 2
(INTERMEDIATE SEVERITY)
1.
2.
3.
4.
5.
6.
Office of Internal Investigations *
Program Director (may determine to refer to investigations)
Associate Program Director
Supervisor
Case Manager *
Any other appropriate entity
LEVEL 3
(MINIMUM SEVERITY)
1.
2.
3.
4.
Associate Program Director (may determine to refer to PD or investigations)
Supervisor
Case Manager *
Any other appropriate entity
LEVEL 4
(INFORMATION ONLY)
1.
2.
3.
4.
Associate Program Director (may determine to refer to PD or investigations)
Supervisor
Case Manager *
Any other appropriate entity
*required by private provider
Page 16 of 20
Facility/Program Name
#10 – ****
Incident Report
Juvenile(s) Involved:
Case #
Last, First, Middle Name
Case #
1)
2)
3)
MM
Last, First, Middle Name
4)
5)
6)
Date
DD
Time of Incident
Military Time
YY
Incident Location
Staff on shift:
Witness(es):
1)
2)
3)
4)
5)
1)
2)
3)
4)
5)
A.
>
Description of Incident:
B.
Use of Force Accounting (must be filled out anytime force is used):
Justification for Use of Force: (Check all that apply)
 Self Protection
 Prevention of imminent & substantial destruction of property
 Protect youth from self-injury
 Protect others
 Prevent escape from a Division facility
 Overcoming physical resistance of a detainee for failure to
comply with a reasonable order by the staff
Type of control hold attempted or applied:
>
Injury sustained as a result of the use of force: (Check all that apply)
 Staff
 Juvenile
 None
 Other:
Describe what type of injury(s) was sustained and what was done about the injury(s):
>
If injury(s) required medical personnel to respond please indicate who responded (by name and date of the
response):
>
Injury Accounting (must be filled out anytime an injury is seen or reported)
Excluding injuries already accounted for in Section B.
Describe what type of injury(s) is seen or reported:
>
Describe what was done about the injury(s):
>
If injury(s) required medical personnel to respond please indicate who responded (by name and date of the
response):
>
C.
D.
Action Taken:
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>
Level of Severity (1-4)
Classified as:
>
Attachments:
 Supplemental Report  Diagram  Evidence  Surveillance Video  Other:
Check all that apply:
 Youth on Staff
 Youth on Youth
 Youth on Non-Employee
 Staff on Staff
 Staff on Youth
 Staff on Non-Employee
 Used force by way of ICR to control
 Used Mechanical Restraint(s) to control
 Self Inflicted Injury
 Injury Requiring Medical Attention
>
Name of Reporter (Print/Type)
>
Signature of Reporter
 Medical Attention Required
 Law Enforcement Involvement
 Other Agency Involvement:
>
APD Initials
>
Title of Reporter
MM
DD
YY
Form revised 10-22-09
Page 18 of 20
Facility/Program Name
Supplemental Report
Juvenile(s) Involved:
Case #
Last, First, Middle Name
Case #
1)
2)
3)
MM
Last, First, Middle Name
4)
5)
6)
Date
DD
Time of Incident
Military Time
YY
Incident Location
Staff on shift:
Witness(es):
1)
2)
3)
4)
5)
1)
2)
3)
4)
5)
A.
>
Description of Incident:
B.
Use of Force [Policy 05-07]
Justification for Use of Force: (Check all that apply)
 Self Protection
 Prevention of imminent & substantial destruction of property
 Protect youth from self-injury
 Protect others
 Prevent escape from a Division facility
 Overcoming physical resistance of a detainee for failure to
comply with a reasonable order by the staff
Type of control hold attempted or applied:
>
Injury sustained as a result of the Use of Force: (Check all that apply)
 Staff
 Juvenile
 Other:
Describe what type of injury(s) was sustained and what was done about the injury(s):
>
If injury(s) required medical personnel to respond please indicate who responded (by name and date of the
response):
>
Injury Accounting (must be filled out anytime an injury is seen or reported)
Excluding injuries already accounted for in Section B.
Describe what type of injury(s) is seen or reported:
>
Describe what was done about the injury(s):
>
If injury(s) required medical personnel to respond please indicate who responded (by name and date of the
response):
>
C.
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D.
>
Action Taken:
OFFICE USE ONLY
Incident #
>
Name of Reporter
>
Signature of Reporter
>
APD Initials
>
Title of Reporter
MM
DD
YY
Form revised 10-22-09
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