At-Risk Notification Form
v1.5
Purpose. Any staff member who observes signs that a person in custody is at risk of self-harm, suicide or serious deterioration completes this form to trigger a Risk Assessment and Intervention Team review.
1.When to use this form
Complete this form as soon as you observe or are told of a risk indicator. Do not wait for the end of shift. Radio the Senior Officer first if the risk is immediate, then complete the form.
- Statements about self-harm or suicide
- Giving away property
- Withdrawal, tearfulness or agitation
- Bad news from court, family or parole
- Recent placement change or bullying
- Refusing food or medication
2.Immediate actions
Record what you have already done, including who you told, whether the person has been moved, the observation level set and whether the health provider has been contacted.
3.Routing
Hand the form to the Senior Officer, who must notify the health provider and the case manager and record the notification in the Offender Case Management system. The Risk Assessment and Intervention Team will review the person the same day.
4.Confidentiality
This form contains health information and must be stored in the person's confidential file. Do not discuss the content with other prisoners or with staff who do not need to know.
5.Follow up
The case manager will record the outcome of the review and the observation plan against the person's record. The notifying officer will be told the outcome where it affects their supervision of the person.