105 Information Report

IR#:

Date:

Time:



Location:

Type of Incident:


Individuals Involved:
Name:


IDOC#:


Name:


IDOC#:


Name:


IDOC#:


 (Add additional rows if necessary)
Information Report (Who, What, When, Where, How, And Why):




--Print Form--
Reporting staff and associate #:


Signature:



Submitted to:

Date:



Supervisory Review

Shift commander/supervisor:

Associate ID #:

Date:


Action(s) taken:

Administrative Review

Investigator (if applicable):
Action taken by:

Associate ID #:

Date:


Action(s) taken:

Security manager:

Associate ID #:

Date:


Action(s) taken:

Deputy warden (equivalent):

Associate ID #:

Date:


Action(s) taken:

Deputy warden (equivalent):

Associate ID #:

Date:


Action(s) taken:

Facility head:

Associate ID #:

Date:


Action(s) taken:

Filed (location):

Date: