Perf-Based Stds, Adult Corr. Inst. 5th ed March 2021

Appendix H: Significant Incident Summary

Facility Name:_______________________________________________________________ Reporting Period: ___________________________________________________________

Total for Reporting Period

Months ➡

Incident Type

Escapes

Disturbances*

Sexual Violence

Offender Victim Staff Victim Other Victim Offender/ Offender Offender/ Staff

Homicide*

Assaults

Suicide

Non-Compli- ance with a Mandatory Standard*

Fire*

Natural Disaster*

Unnatural Death

Other*

*May require reporting to ACA using the Critical Incident Report as soon as possible within the context of the incident itself.

280 Adult Correctional Institutions, Fifth Edition