105 Incident Notification Report

Date of Incident:      Time of Incident:      
Correctional Facility: Probation and Parole District:
Location of the Incident:
Facility (building/unit etc.):      
Vocational work projects:      
Community:      
County jail:      
In transit:      
Hospital:      
Other:      
Type of Incident:
Accidental injury requiring medical attention:
Alternative meal service:
Arrest or target of criminal investigation: Charge:      
Assault or battery: Type:
Bomb threat:
Contraband (significant): Correctional facility Probation and parole district
Escape/walk-away: Fire:
Group disruption:
Hazardous material incident
Offenderdeath:
Physical plant/utility problem
Property loss greater than $500:
Restraints: Long-term (if not a restraint chair, describe in summary):
Search of an offender’s visitor’s person or vehicle
Sexual misconduct offender:
Suicide:
Suicide watch:
Unscheduled medical transport
Use of force: Detail:
Utility outage:
Vehicle accident (over $1000 or injury): Injuries involved
Individual(s) Involved:
Offender name(s) and number(s):      
IDOC staff name(s):      Contract staff name(s):      Facility visitors:     
General public:      Emergency services:
Brief summary of incident and action taken:     
Administrative duty officer notification: Called Not calledUnable to contact
Medical check completed:Yes No Injuries: Yes No(If yes, briefly explain extent of injuries)     Email to: [105 chain of command]Email sent by: