DEPARTMENT OF CORRECTIONS INCIDENT REPORT - FLRules

Reporting Institution: Reporting Employee: Employee ID Number: Person(s) Involved:

DEPARTMENT OF CORRECTIONS INCIDENT REPORT

Incident Report Number: PREA Number: Date of incident: Time of incident: Witness(es):

Control Room Log Entry Made: Inmate Placed in Confinement: Duty Warden Notified: EAC Notified: Supporting Documents Attached

DETAILS OF INCIDENT:

Yes No Yes No Yes No Time: Yes No Time:

Disciplinary Report Initiated: Yes No

Work Order Initiated:

Yes No

MINS Initiated:

Yes No

Duty Officer Name:

Reporting Employee's Name (Print) Shift Supervisor/ Department Head COMMENT:

Reporting Employee's Signature

Date

Shift Supervisor's/ Department Head's Name (Print) REVIEW:

Shift Supervisor's Signature

Date

Correctional Officer Chief's Name (Print) REVIEW:

Correctional Officer Chief's Signature

Date

Warden's Name (Print)

Warden's Signature

DC6-210 (Effective 12/12)

Incorporated by Reference in Rule 33-602.210, F.A.C.

Date Page 1 of 2

DETAILS OF INCIDENT (cont.):

SHIFT Supervisor/ Department Head COMMENT (cont.): REVIEW (cont.): REVIEW (cont.):

DC6-210 (Effective 12/12)

Incorporated by Reference in Rule 33-602.210, F.A.C.

Page 2 of 2

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