Code of Maine Rules › 03 - DEPARTMENT OF CORRECTIONS › 201 - DEPARTMENT OF CORRECTIONS/GENERAL › Chapter 1 - DETENTION AND CORRECTIONAL STANDARDS FOR COUNTIES AND MUNICIPALITIES › Section 201-1-II - COUNTY JAILS › Appendix 201-1-II a-E - INMATE INTAKE/SCREENING FORM

Current through 2024-29, July 17, 2024
Inmate's Name
Date of
								Birth
Sex
Date
Time
Most Serious Charge
Report Number
Screening Officer
Was inmate a medical, mental health or suicide risk during
					 any prior contact or confinement with your department"
 Yes  No If Yes,
					 when:____________________________________________________
Does the arresting or transporting officer believe that
					 inmate is a medical, mental health or suicide risk now"
 Yes  No
OFFICERS' OBSERVATIONS
YES NO YES NO
_____
_____ Assaultive/Violent Behavior ____ _____
					 Crying/Tearful
_____ _____ Loud/Obnoxious Behavior ____ _____
					 Confused
_____ _____ Any Noticeable Marks/Scars ____ _____
					 Uncooperative
_____ _____ Bizarre Behavior ____ _____
					 Passive
_____ _____ Alcohol/Drug Withdrawal ____ _____
					 Intoxicated
_____ _____ Unusual Suspiciousness ____ _____
					 Scared
_____ _____ Hearing Voices/Seeing Visions ____ _____
					 Incoherent
_____ _____ Observable Pain/Injuries ____ _____
					 Embarrassed
_____ _____ Other Observable Signs of ____ _____
					 Cooperative
Depression
					 explain:_______________________________________
MEDICAL HISTORY
YES NO
_____ _____ Are you injured" If Yes,
					 explain:______________________________
_____ _____ Are you currently under a physician's
					 care" If Yes, explain:
_____ _____ If female, Are you
					 pregnant"
_____ _____ Are you currently taking any medication"
					 If Yes, list type(s), dosage(s), and frequency:
__________________________________________________________
DO YOU SUFFER FROM ANY OF THE
					 FOLLOWING:
YES NO YES NO
_____ ______ Hepatitis ____ ______ Heart
					 Diseases
_____ ______ Shortness of Breath ____ ______ Chest
					 Pain(s)
_____ ______ Abdominal Pain(s) ____ ______
					 Asthma
_____ ______ High Blood Pressure ____ ______ Venereal
					 Disease
_____ ______ Tuberculosis ____ ______
					 Diabetes
_____ ______ Alcohol Addiction ____ ______ Drug
					 Addiction
_____ ______ Epilepsy/Blackouts/Seizures ____ ______
					 Ulcers
_____ ______ Other Medical Problems and/or Diseases
					 ____ ______ AIDS (Optional)
explain:_____________________________________________________
SUICIDE ASSESSMENT
YES NO
____ ____ Have you ever attempted suicide" If Yes,
					 When"____________________________________
Why"___________________________________
					 How"_______________________________
___ ____ Have you ever considered suicide" If
					 Yes,
When"__________________________________
					 Why"_______________________________
___ ____ Are you now or have you ever been treated
					 for mental health or emotional Problems" If Yes
When"_________________________Inpatient:_________Outpatient:________Both______
____ ____ Have you recently experienced a significant
					 loss (job, relationship, death or family member/
close friend, etc.)" If Yes, explain:
_____________________________________________________________________________
____ ____ Do you feel that there is nothing to look
					 forward to in the immediate future
(expressing helplessness and/or hopelessness)" If
					 Yes, explain:
___________________________________________________________________________
____ _____ Are you thinking of killing yourself" If
					 Yes, explain:_________________________________
Additional
					 Remarks:__________________________________________________
__________________________________________________________________________________________
DISPOSITION
 General Population
 Special Watch
1)
Supervision Levels: Active (5-15
				  minutes) ____ Constant ____
2)
Housing Assignment: Cell # _____
				  Cell # _____ Other __________________
3)
Other precautions taken (removal of
				  clothing, bedding, etc., If appropriate)
__________________________________________________________________________________________
 Medical Hospital. If inmate is later returned to
					 facility, list any special watch recommendations.
__________________________________________________________________________________________
 Mental Health Service. If inmate is later returned
					 to facility, list any special watch recommendations.
__________________________________________________________________________________________
 Other
					 dispositoin/referral/transfer__________________________________________________________
FAILURE TO ANSWER/REFUSAL OF TREATMENT
Inmate refused to answer (circle) or unable to answer
					 (circle and state why) the verbal response sections of this screening
					 form.
I, __________________________(print name), refuse any
					 type of medical treatment.
SIGNATURES:
					 Inmate:_________________________________
Screening
Officer:______________________________________
					 Supervisor:_________________________________