Suicide Risk Assessment

Date Placed on Acute Watch:
Date Placed on Non-Acute Watch
Date Placed on Observation
Date Removed from Watch/Observation
Enter date
Enter date
Enter date
Enter date
Inmate name (last/first):       IDOC #:       DOB:       Report Date: Enter date
Facility: Choose Facility. Offense:       Regular Unit:       Current Unit:      
Current Level of Care (LOC): Choose an item.
SRA Report Type: Choose an item.Risk Level: Choose an item.
Reason for Referral:      
Mental Status Exam
Alert, Oriented x4
Disoriented
Reports Hallucinations
Endorses Delusions
Grooming/ Hygiene
Eye Contact
Affect
Mood
Thought Process
Speech
Movement Activity
Appropriate to situation
Appropriate to situation
Appropriate to situation
Appropriate to situation
Appropriate to situation
Appropriate to situation
Appropriate to situation
Neat/Clean
Fair
Flat
Angry
Logical
Rapid
Restless
Unkempt
Good
No Emotion
Cheerful
Goal directed
Slow
Slowed
Dirty
None
Tearful
Calm
Disorganized
Pressured
Active
Other

Smiling
Sad
Moving from topic to topic quickly
Slurred
Agitated
Depressed
Hopeless
Irrelevant
Loud
Aggressive
Euphoric
Anxious
Distractible
Quiet
Rambling
Interview:      
Intent to Die:      
Degree of Medical Intervention: Choose an item.
Plan or Method:      
Inmate’s Stated Intent: Choose an item.If other explain:      
Access to Means:      Last Suicide Watch: Choose an item.
Historical Factors (check all that apply)
Family history of suicide
First time prison term
Inmate history of suicide attempts
Current Ad Seg
History of substance abuse
Other:      
Known Stressors/Demographic Predictors (check all that apply)
Sleeping difficulties or irregular sleeping hours
Recent persona loss or crisis
Non-compliance with prescribed psych medications
Neglect of personal hygiene
Weight loss of loss of appetite
Long or life sentence
Progressive health Problems (chronic or terminal illness)
Poor compliance with treatment
DOR
Conflict on tier
Family event
Conflict with bunkmate
Gambling or other debt
Parole/court hearing
Fearful for safety
Relationship
Other:      
Psychological Factors:      
Protective Factors:      
Evaluation of Risk Potential:      
Precise prediction of suicide and other self-injurious behavior is difficult, of limited reliability, and diminishes significantly over time. However, based upon the historical information,
an individual interview, existing environmental conditions, and other information available at the time of the review, inmate’s current level of risk probably of suicide is reflected
below. This level of risk will change over time and should be modified as circumstances change.
Change in LOC Required? Choose an item.
New LOC if Applicable (enter in CIS if LOC has changed): Choose an item.
Treatment Plan Update: Choose an item.
Recommendations:      
Risk Reduction Plan
Problem: (Specific to the inmate’s current reporting issues)      
Goal: (Two types of goals for each problem: immediate goals and short-term goals)      
Intervention: (Specific and measureable to two types of goals and related to the presenting problem)      
Clinician:       Employee Associate #:       Credential(s):       Date:      
Signature:
IDAHO DEPARTMENT OF CORRECTION
Suicide Risk Assessment
315.02.01.001
(Form last updated 11/02/2016)Page 2 of 2