Inmate Vulnerability Assessment (Page 1)

Results (circle one)

Inmate Name:
Gender: - - -

Race: - - -

Date of Assessment:
Conducted By:

DOB: - - - - -

_O=-.c5:..:./..:..05
=/-=2~0=-20.:;___ _ __ _ _ _ _ __

_C=.;P:_L=·:....:G=-O=D-=-W.:...:lc:....:N'------- - --

Shift Sergeant:

---

Vulnerable to Victimization

Yes

Sexually Aggressive

Yes

No Designated Cellmate

Yes

Mental Health Referral

Yes

@
@
@
@

RISK LEVEL (circle one)

SGT. SMITHEY

(Low)

HIGH

MEDIUM
SCORE

1. Experience in Institution
Yes (OJ

No (2J

0

Do you feel you get along with other people?

Yes (OJ

No (1J

0

Do you find it easy to make friends?

Yes (OJ

No (1J

0

Do you feel "ok" in large groups of unknown people?

Yes (OJ

No (1J

0

Yes (1J

No (OJ

0

Often (4J

2

Yes (4J

No (OJ

0

Have you ever been arrested for a sexual charge?

Yes (4J

No (OJ

0

Have you ever been arrested for a violent charge?

Yes (4J

No (OJ

4

Have you ever been arrested?
2. Social Skills

3. Perception of Risk

Do you feel at risk of attack or abuse?
For example - have you received threats, insults, and harassment from others?

4. History of Victimization
Have you ever been attacked, bullied, or abused by your peers?
Never (OJ

Sometimes (2J

Have you ever had a sexual experience that you did not want to have?
If the inmate answers yes, does the inmate want mental
health assistance with this issue?

Yes

No

5. Offense Type

6. Other
Have you ever engaged in behavior that you would consider violent or sexually aggressive ?
Yes (4J

Age of Inmate

18-44 (0)

Evidence of Intellectual Impairment?

45-54 (1)

55-64 (2)

No (OJ

0

65+ (3)
Yes (2J

No (0)

Total Page 1

7

Inmate Vulnerability Assessment (Page 2)

08-0~()9,;tJ.,a
7. "Lack of Fit"
The following items require judgment from the screener that the inmate is unlikely to "fit in" w ithin the
mainstream population (Check all that apply).
Physical Appearance

Small Build
Looks Young
Impaired Vision
Pronounced Disfigurement
Physical Disability
Deaf
Appears Frail; Weak
Presentation and Behavior

Inappropriate verbal behavior (giggling, odd remarks, etc.)
Inappropriate physical behavior (men wearing make-up, sexual behavior, etc.)
Hunched, fearful posture
Obvious effeminate behavior (males)
Obvious masculine behavior (females)
Acts of aggression in presence of screener
Speech Impediment
Appears Slow
Behaviors that are likely to annoy other inmates (immature, silly, etc.)
Behaviors that appear related to mental illness (jittery, crying, bizarre, etc.)
Features which make him/her stand out

Having a lack of exposure to criminal lifestyle
Being from ethnic minority not represented in general population
Membership in a gang that is likely to be targeted
Inmate is detained solely for Civil Immigration Purposes (no score)

If any other features that raise concern exist, please note...

SCORE: None to One of the above (0) I Two or Three of the above (2) I Four or more of the above (4)

Page 1 Total

7

Total Score

7

RISK LEVEL BASED ON TOT AL SCORE
Low (0-8)

Medium (9-16)

0

High (17 and above)