Medical Consideration Request Form

IDAHO DEPARTMENT OF CORRECTION
Medical Consideration Request Form
Offender Information
Offender's Name: IDOC #:
Facility: --Select--
Consideration 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 medical consideration on the above
named offender:
® Cane ❑ Lower Level or Tier
❑ Cotton Blanket ❑ Oxygen Dependant
❑ Crutches ❑ Vision Impaired
rJ Gym or Recreation Restriction ❑ Walker
❑ Handicap Access Required ❑ Wheelchair
❑ Hearing Impaired ❑ Other (written justification is required for this selection)
❑ Lower Bunk
Consideration Start Date: Consideration End Date:
Comments:
When completed, email this form to the designated healthcare services staff per SOP
322.02.01.003.
Designated Healthcare Services Staff Use Only
Comments (if needed):
CIS data entry completed by: Date:
(Print Name)
Appendix F
322.02.01.003
(Appendix last updated 7/14/11 )