Inmate Medical and Suicide Risk Screening Form

Intake screening form to identify urgent medical conditions, current medications, and suicide risk factors so appropriate observation and referral actions can be taken.

Intake and Screening Consent

• Screening date
• Screening time
• Screened by
• Inmate ID
• Consent and disclosure acknowledgement
• Anonymous submission
  Use only if your facility allows anonymous safety reporting. For intake screening, this should typically remain unchecked because the screening must be linked to the correct person.

Immediate Medical Concerns

• Is the person experiencing a current medical emergency?
• Describe the emergency
• Hospitalization or emergency care in the last 30 days?
• Provide details
• Mobility, sensory, or disability-related accommodation needs
  Select any needs that may affect safe housing, observation, or access to care.

Current Medications and Health Conditions

• Is the person currently taking any medications?
• List current medications
• Known chronic medical conditions
• Describe other condition
• Known allergies or adverse reactions

Suicide Risk Screening

• Are you having thoughts of hurting yourself or ending your life right now?
• Any suicidal thoughts in the past 30 days?
• History of suicide attempt or self-harm?
• Describe history of attempt or self-harm
• Current plan, intent, or access to means?
• Protective factors or reasons for living

Observation, Referral, and Final Disposition

• Assigned risk level
• Observation placement required?
• Observation type
• Referral or follow-up actions
• Final notes