Safety Concern Form

IDAHO DEPARTMENT OF CORRECTION
Safety Concern Form
Offender Information
Offender's Name: IDOC #:
Facility: --Select--
Concern Information
Initiator's Name:
In accordance with standard operating procedure 322.02.01.003, Holds, Cautions, Concerns,
and Considerations: Offender, I am requesting the following safety concern on the above named
offender:
❑ Offender Conflict
❑ Self-injurious Behavior or Thoughts
❑ Staff Conflict (you may need to also submit a Relationship Disclosure Form)
Concern Start Date: Concern End Date:
Comments:
When completed, submit this form to the Offender Placement Group (as identified in the Novell
GroupWise address book).
Offender Placement Group Use Only
Comments (if needed):
CIS data entry completed by: Date:
(Print Name)
Appendix E
322.02.01.003
(Appendix last updated 7/14/11 )