415

THE CITY OF NEW YORK
DEPARTMENT OF CORRECTION

DIREC11VE
[X]

NEW

[]

INTERIM

EFFECTIVE DATE

]

REVISED

*TERMINATION DATE

/

1 2/1 0/03
CLASSIFICATION

#

. [

SUPERSEDES

/
DATED

SUICIDE PREVENTION
DISTRIBUTION

A

4521
RECOMMENDED FOR APPROVAL BY REVIEW BOARD MEMBER

ROBERT N.

I.

SUBJECT

OF

PAGE

1

15

PAGES

ORIZED BY THE COMMISSIONER

SIGNATURE

SIGNATURE

PURPOSE
To establish guidelines for ensuring the health, safety and welfare of diagnosed and
potentially suicidal inmates in the custody of the New York City Department of
Correction.

II.

III.

POLICY
A.

All inmates who are at risk for suicide shall be placed on suicide watch by medical/
mental health staff. In order to prevent suicide, constant supervision shall be
implemented by the Department when an inmate is placed on suicide watch by
medical/mental health staff.

-8.

Whenever possible, inmates in suicide watch status shall be housed in dormitory
settings. Cell housing can be utilized for inmates as indicated by a mental health
clinician based on clinical appropriateness (e.g., those in need of observation,
and who are also assaultive).

DEFINITION
A.

_Constant Supervision - The uninterrupted personal visual observation of inmates
(without the aid of any electrical or mechanical surveillance devices) and
continuous and direct supervision by permanently occupying an established post
in close proximity to the inmate under supervision. Staff shall be provided with:
1.

A continuous clear view of all prisoners under supervision; and

2.

The ability to immediately and directly intervene in response to situations
or behaviot observed which threaten the health or safety of prisoners or
the good order of the facility.

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EFFECTIVE DATE

SUBJECT

12/10/03
CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES
A.

Identifying Inmates at Risk for Suicide
Staff shall perform routine tours of their assigned posts, observing the inmates
in their custody for unusual incidents, behavior or conditions. During tours of
inspection, staff must remain alert for any behavior displayed by an inmate that
may indicate he/she is mentally ill or suicidal.
The following guidelines have been established in an effort to decrease the number
of suicidal attempts. These guidelines cover environmental causes, pre-disposing
factors, high risk suicidal periods, and warning signs and symptoms.
1.

CHARACTERISTICS OF JAIL ENVIRONMENT WHICH ENHANCE SUICIDAL
BEHAVIOR
These characteristics include:
a.
b.
c.
d.
e.
f.

2.

Fear of the unknown;
Authoritarian environment;
No apparent control over the future;
Isolation from family and significant other;
Shame of incarceration; and
Dehumanizing aspects of incarceration.

POTENTIAL SUICIDE PRE-DISPOSING FACTORS
These factors include:
a. Recent excessive drinking or drug use (e.g., detoxing/withdrawing);
b. Recent loss of stabilizing resources (e.g., break-up with spouse or
significant other);
c. Severe guilt or shame over the offense (e.g., sexual offense);
d. Same-sex rape or threat of such;
e. Current mental illness;
f. Poor physical health or terminal illness;
g. Court officials indicate suicide watch/alert on securing order;
h. Recently sentenced, facing a long sentence;
i. Inmate is a "Pillar of Society" (e.g., clergy, politician, professional,
etc.);
J. Charged with a capital offense;
k. Violent felony (e.g., murder, rape, arson);

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EFFECTIVE DATE

SUBJECT

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CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)
I. Violent history;
m. Culture considers suicide honorable (Immigrants);
n. Family history of suicide or prior suicide attempts; and
o. Experienced a personal tragedy.
3.

HIGH RISK SUICIDE PERIOD
These periods include:
a.
b.
c.
d.
e.
f.
g.

4.

The first 24 hours of confinement;
Intoxication/withdrawal;
Trial and sentencing hearings;
Impending release;
Decreased staff supervision;
Weekends and holidays; and
Bad news from home/attorney.

WARNING SIGNS AND SYMPTOMS OF SUICIDAL BEHAVIOR
Specific behaviors that may indicate mental illness or a propensity for
suicidal ideation include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Talking about or threatening suicide;
Writing a will and/or suicide note;
Sadness and crying;
Withdrawal, silence;
Sudden loss or gain in appetite;
Insomnia;
Lethargy;
Projecting hopelessness or helplessness;
Speaking unrealistically about future and getting out of jail;
Giving away possessions and/or packing belongings;
Increasing difficulty relating to others;
I. Severe aggressiveness; and
m. Paranoid delusions or hallucinations.

B.

Suicide Prevention Screening
Screening and assessment when inmates enter a facility are critical.

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EFFECTIVE DATE

SUBJECT

12/10/03
CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)
1.

All court divisions will complete the State of New York Commission of
Correction Office of Mental Health (NYSCOCMH) form #330.

2.

All facility intake areas will complete form #330 for any inmates who are
not processed through the court division, such as state transfers, direct
police cases, direct parole cases, etc.

3.

The original form #330 will be attached to the arraignment form #239AR
and become a permanent part of the inmate's legal folder. A copy will be
forwarded to medical staff for completion and will be included in the inmate's
medical folder.

4.

All checks in column A will be totaled in the space provided. The screening
officer will notify a supervisor immediately if form #330 indicates:
a. A total score of 8 or more;
b. Any shaded boxes are checked; or
c. The screening officer feels that notification is appropriate.

5.
C.

Indication of potential suicide will result in an immediate referral to mental
health staff.

Suicide Prevention Procedures for Court Divisions
Correction Officers assigned to Court Divisions perform routine tours of their
assigned posts, observing all inmates in their custody for unusual incidents,
behavior or conditions at a minimum of every 15 minutes. During tour of
inspection, staff must remain alert for any behavior displayed by an inmate that
may indicate he/she is mentally ill or suicidal.
1.

Inmates identified as being at risk for suicide (according to the guidelines
set forth in III. Procedures, A. Identifying Inmates at Risk for Suicide of this
Directive) shall be interviewed in private by a supervisor and their belts,
shoelaces, drawstrings, neckties, etc. will be confiscated and safeguarded.
Form #4018R, entitled "Referral of Inmates to Mental Health Services", shall
be completed and attached to the inmate's securing order.
Increased monitoring shall be performed including:
a. Placement of the inmate within direct line of sight of the officer;

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SUBJECT

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CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)
b. Constant supervision; and
c. Ongoing verbal communication with· the inmate.
2.

Confiscated property will be taken in accordance with C. 1 above and placed
in an appropriately sized envelope, which will be attached to the inmate's
securing order. The property will be forwarded with the inmate to his/her
housing facility and processed in accordance with current procedures
regarding the safeguarding of inmate property.

3.

If the subject inmate is an adult male new admission, he will be transported
to the Anna M. Kross Center (AMKC) for new admission processing and a
mental health evaluation.

4.

Upon the arrival of the subject inmate to his/her housing facility he/she
shall be escorted without delay to the clinic for a mental health evaluation
in accordance with the procedures set forth in Directive 4018R "Referral of
Inmates to Mental Health Services".

5.

Suicide Watch Inmates and Court Appearances
When suicide watch inmates are produced to the court officer from the
Office of Court Administration (OCA) for court appearance the following
procedures shall apply:
a. The suicide watch sheet shall remain with the court division officer, and
the time that OCA assumes custody shall be noted on the Suicide Watch
Report.
b. The court officer shall sign for the inmate in the Court Division Record
Logbook (242A).
c.The remarks section of the Court Division Record Logbook (242A) shall
be inscribed with the remark "suicide risk."
d. The court officer accepting custody of the inmate shall place his/her
initials next to the remarks section that indicates that the inmate is a
"suicide risk."

6.

On-Trial Suicide Watch Inmates

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SUICIDE PREVENTION

CLASSIFICATION

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PROCEDURES (continued)
On-trial suicide watch inmates will be permitted to wear a belt, necktie
and shoelaces while they are in the courtroom only.
a. The sending facility shall place the inmate's property in an appropriately
sized envelope, which will be attached to the accompanying card and
given to the transportation officer. The outside of the envelope will list
the contents (i.e. one black belt, one gray tie, etc.).
b. Before being placed in OCA custody, the inmate will receive his/her
property for his/her court appearance.
c. Once the inmate returns from his/her court appearance the property will
be taken from the inmate by the court division officer before the inmate
is placed in the holding pen. The court division officer shall ensure that
the contents listed on the property envelope are returned.
D.

Initiation of Suicide Watch
1.

If any employee suspects that an inmate may be suicidal or a suicide risk
even without demonstrating overt suicidal behavior, the employee must
immediately notify a supervisor. The inmate shall be immediately referred
to mental health by utilizing "Referral of Inmates to Mental Health Services"
form #4018.

2.

The supervisor will direct that any items that may be used to cause selfharm are confiscated from the at-risk inmate including but not limited to:
a. belts;
b. shoelaces;
c. drawstrings, and;
d.

3.

neckties, etc.

The initiation ofa suicide·watch may occur after any evaluation by a mental
health/medical practitioner. If the clinician determines that a suicide watch
is necessary, he/she shall identify the type of housing the inmate should be
assigned to (e.g., Mental Observation [MO], Mental Health Assessment Unit
for Infracted Inmates [MHAUII], Administrative Mental Observation Unit
[AMOU]), as well as whether the area should be dormitory or cell.

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EFFECTIVE DATE

SUBJECT

1 2/10/03
CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)
Note: Only a mental health/medical staff member may initiate a suicide watch.
E.

Notification to DOC by Mental Health/Medical Staff
1.

When mental health/medical staff initiate a suicide watch, a Mental Health
Status Notification and Mental Observation Transfer Form (TNF) form #
OD/HS 02 indicating the initiation of the watch, the type of housing,
dormitory/cell and any necessary precautions will be forwarded to the tour
commander and movement control.

2.

The following information shall be indicated on the TNF:
a. The reason for issuing or contra-indicating the use of the suicide
prevention smock; and
b. The duration of time that the inmate will be required to wear the suicide
prevention smock / paper gown.

Note:

F.

Inmates may elect to wear the paper gown in lieu of the suicide prevention
smock.

3.

Mental health staff will house any male inmate on suicide watch status in
AMKC/Mental Health Center (C-71), with the exception of those inmates
housed in GRVC/MHAUII, West Facility/Contagious Disease Unit (CDU), NIC
Infirmary, or NIC/AMOU.

4.

The Rose M. Singer Center (RMSC) will house female inmates on suicide
watch status in a mental health dormitory dedicated to enhanced suicide
observation with the exception of those inmates housed in MHAUII, West
Facility/CDU or the Infirmary.

Processing of Inmates on Suicide Watch Status
1.

The inmate's identification card will be exchanged to receive a new
identification card with a black circle identifier;

2.

The accompanying card receives a black circle identifier;

Note:

Upon removal from suicide watch status the black circle identifier will be
removed from the inmate's accompanying card and the identification
card will be exchanged for a new card.

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EFFECTIVE DATE

SUBJECT

1 2/1 0/03
CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)
3.

All inmates housed on suicide watch within a dormitory designated for suicide
watch will surrender all clothing and linen items. The only exception will be
those items that mental health/medical staff indicate on the TNF should
not be surrendered. The inmate's property will be handled in accordance
with Directive 2307R, Surrender and Safekeeping of Inmate Property.

4.

Inmates on suicide watch will receive the following suicide prevention items:
a. one (1) suicide prevention smock, (see #5)
b. two (2) suicide prevention blankets,
c.

disposable undergarments as needed, and

d. one (1) finger toothbrush.
5.

The following instances would preclude an inmate on suicide watch from
donning the suicide prevention smock:
a. Mental health/medical staff contraindicate the use of the suicide
prevention smock.
b. Inmates that are housed in a mental health dormitory where all inmates
are not donning a suicide prevention smock will be allowed to maintain
their clothing and linen items.
c. Inmates that are housed in cell areas where all inmates are not wearing
smocks shall only don the smock while in their cells. They shall exchange
the smock for a jumpsuit whenever leaving the cell.

6.
G.

The suicide prevention smocks will be exchanged daily. Disposable
undergarments will be exchanged as needed, but no less than daily.

Housing
1.

Any inmate who is identified as a suicide risk will be assigned to a housing
area that can provide direct and constant supervision and escorted movement
for such a period of time as determined by the appropriate clinical staff.
Note: Mental health/medical staff shall make daily rounds of all areas where
inmates on suicide watch are housed.

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EFFECTIVE DATE

SUBJECT

12/10/03
CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)

H.

2.

Suicidal inmates will be assigned beds/cells that are nearest to the officer's
station.

3.

Cells must be checked prior to placing a suicidal inmate inside the cell to
ensure that all potentially harmful articles are removed. Contraband searches
should be conducted daily thereafter, be unannounced and be observed by
a supervisor and documented in the post logbook.

Movement of Inmates Placed on Suicide Watch
1.

Movement Within Housing Facility
a. Whenever an inmate on suicide watch attends programs (e.g., recreation,
visits, law library, etc.) the inmate shall be escorted and his/her Suicide
Watch Report (form #4521 A) shall be given to the program officer.
The program officer will ensure that the inmate is observed and the
Suicide Watch Report is completed and returned with the inmate to his/
her housing area.
The program officer shall notify his/her supervision to determine if the
staffing in the program/service area is adequate to afford constant
supervision of the suicide watch inmate. If the supervisor determines
that it is not, then the escort officer shall remain with the inmate.
b. All inmates on suicide watch will change from a smock into a jumpsuit
during all out of housing area activities and extra-facility movement.
c. A minimum of two (2) jumpsuits per suicide inmate will be maintained
in the "A" station daily.

2.

Movement Outside of Housing Facility
a. Whenever an inmate on suicide watch status travels outside of the housing
facility, (e.g., court, clinic, hearing, etc.) his/her Suicide Watch Report
(form #4521 A) shall be attached to the accompanying card (form #239)
and the escort/transportation officer shall be made aware that the inmate
is on suicide watch.
The inmate will be seated close to the officer, within line of sight. The
escort/transportation officer will ensure that the inmate is observed
and his/her findings are recorded on the Suicide Watch Report every 15
minutes.

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EFFECTIVE DATE

SUBJECT

12/10/03
CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

IV.

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PROCEDURES (continued)
The escort/transportation officer shall deliver the inmate's paperwork
and Suicide Watch Report sheet to the receiving officer. The receiving
officer shall be responsible for ensuring that the inmate is placed in a cell
close to the officer within line of sight and ensure that the inmate is
observed and his/her findings are recorded on the Suicide Watch Report
every 15 minutes.
b. In instances where the required checks were not documented and/or
conducted, the employee responsible for conducting the checks shall
document (by memo, form GODAR) the reason(s) and submit his/her
report to the area supervisor. If the Tour Commander accepts the
explanation, a copy of the memo shall be attached to the Suicide Watch
Report. If the explanation(s) is not acceptable, appropriate corrective
action will be taken.
Note:

All completed Suicide Watch Reports must be submitted to the Control
Room of the facility in which the inmate is housed. The Suicide Watch
Report will be processed daily Monday-Friday by the office of the Deputy
Warden for Programs.

c. Only inmates on suicide watch that are on-trial (not routine court
appearances) will be permitted to wear civilian clothing to court all others
will wear a jumpsuit. Items that may be used to harm oneself will not be
permitted, including but not limited to belts, neckties, shoelaces, or
drawstrings.
I.

Suicide Watch Intervention
1.

Deputy Warden Security - During business hours (or the Tour Commander
during non-business hours and weekends) shall:
a. Determine the number of constant supervision officers assigned to a
. given number of suicide watch inmates. His/her determination will be
based on the physical plant and line of sight available for each housing
area.
Each instance shall be determined on a case-by-case basis. In general, a
dormitory setting will allow for a greater number of suicide watch inmates
per officer, versus a cell setting that may warrant one-on-one coverage.

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CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

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PROCEDURES (continued)
2.

Deputy Warden for Programs - During business hours, shall:
a. On a daily basis, provide the Tour Commander and the Control Room
with an up-to-date roster of inmates on suicide watch and their
location.
b. Review all Suicide Watch Reports forms received and ensure that they
are reconciled with mental health staff and that they are complete and
accurate.
c. Shall hold bi-weekly meetings with the mental health unit chief to ensure
that daily mental health encounters are taking place, review all inmates
on suicide watch, their status and/or possible removal.

3.

Tour Commanders shall:
a. Personally observe suicide watch status inmates during their tours of
inspection of housing areas. Tour Commanders shall confirm their
observation by affixing their initials in the supervisor column and
appropriate time slot on form #4521 A.
b. Peruse the completed forms for any unusual activities by the inmate.
c. Ensure that housing area captains are aware of and personally observe
all suicide watch status inmates during tours of inspections of their
assigned areas.
d. Ensure that sufficient supplies of Suicide Watch Reports are on hand in
the Control Room.

4.

Housing / Area Captains shall:
a. Ensure that all procedures are adhered to in Section 111., F. "Processing of
Inmates ·on Suicide Watch Status" of this Directive.
b. Personally observe suicide watch status inmates housed in their areas of
supervision. Housing area captains shall confirm their observation of the
inmate by affixing their initials in the supervisor column and appropriate
time slot on the Suicide Watch Report.

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CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

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PROCEDURES (continued)
c. Ensure that housing area officers complete the Suicide Watch Report in
the manner prescribed in III. Procedures, I. Suicide Watch Intervention,
4. a-g of this Directive.
d. Ensure that the officer assigned to perform constant supervision is not
assigned any other duties, beyond the constant supervision of the
inmate(s) on suicide watch.
Officers assigned to constant supervision posts must be relieved for
meal and all other tasks that he/she is directed to do other than directly
observe the suicide watch inmate(s). Additionally he/she may not provide
a relief for any officer on the same or adjacent posts.
e. Shall ensure that the relieving housing area supervisor is notified of all
inmates on suicide watch status.
S.

Correction Officers - Officers assigned to areas housing, inmate programs/
services, escorting or transporting inmates in suicide watch status shall:
a. Maintain an adequate supply of Suicide Watch Report forms at their
place of assignment.
b. Ascertain and record the names of all suicide watch status inmates in
the housing area logbook upon assuming their post.
c. Maintain constant supervision and record their observations of each
suicide watch inmate every 15 minutes on the prescribed form and shall
include all activity that transpired in the last 15 minutes of continuous
observation.
Example of a log entry for the period of 1000-101 5 hours: "the inmate
ate lunch in the dayroom."
The report should indicate:

i. The name and shield number of the officer conducting the check;
ii. General condition and attitude of the inmate, e.g., appears fine, calm,
crying, ·etc.

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CLASSIFICATION

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# 4521
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PROCEDURES (continued)
iii. Any peculiar behavior or unusual actions;
iv.

Inmate activity, e.g., watching television, reading a book, etc.

v. The name, title and time of any mental health staff interviewing
subject inmate;
vi. The condition of the suicide prevention items, e.g., smock,
blanket;
vii. The time the inmate arrives or returns to the housing area or
any other program or location.
d. Prepare individual suicide watch forms for all inmates requiring them
for the on-coming tour.
e. Submit the completed suicide watch form to the control room, upon
completion of the 1SOOx2331 tour.

J.

K.

Change or Discontinuance of Suicide Watch Status
1.

The mental health staff will evaluate an inmate on suicide watch within
forty-eight (48) hours after initial placement. The next evaluation will be
conducted within ninety-six (96) hours after the initial evaluation.

2.

Any changes in the status of an inmate's suicide watch shall be communicated
by mental health/medical via the TNF to the Tour Commander, movement
control and Programs Deputy Warden.

3.

The sole authority to discontinue a suicide watch shall reside with mental
health staff, regardless of which medical/mental health clinician orders the
initial suicide watch.

Suicide Watch Tracking Procedures
The following guidelines shall ensure accountability of all inmates placed on suicide
watch:
1.

Medical Services Supervisor (Clinic Captain) - Shall:
Ensure that an updated list of all inmates on suicide Watch is submitted to
the movement office and the office of· the Deputy Warden of Programs
each business day.

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CLASSIFICATION

SUICIDE PREVENTION

# 4521
DISTRIBUTION

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PROCEDURES (continued)
2.

Housing Area Officer
On a daily basis shall ensure that the suicide watch form for each inmate in
his/her custody is forwarded to the control room at the end of the
1500X2331 tour.

3.

11 x7 Control Room Captain
a. On a daily basis shall ensure that all suicide watch forms are collected
and reconciled with the active list of inmates on suicide watch.
b. Ensure that an accurate updated list of all inmates on suicide watch is
maintained in the Control Room.

4.

Deputy Warden of Programs
a. Shall maintain an accurate list of all inmates on suicide watch and their
locations.
b. Shall ensure that the Suicide Watch Tracking Form (#4521 B, which
indicates all inmates under active suicide watch) is forwarded to the
facility's Assistant Chief each business by 1100 hours.
c. Ensure all completed Suicide Watch Reports are delivered to the General
Office for filing in the inmates' folder.

5.

Assistant Chiefs of Division's I & II
Shall ensure that a compilation of the Suicide Watch Tracking Forms are
forwarded to the Offices of the Commissioner, Chief of Facility Operations,
Deputy Commissioner of Strategic Planning & Programs and Assistant
Commissioner of Health Affairs Unit each business day by 1400 hours.

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CLASSIFICATION

SUBJECT

SUICIDE PREVENTION

# 4521
DISTRIBUTION

A

V.

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REFERENCES
A.

New York City Board of Correction Mental Health Minimum Standards;

B.

Directive #2307R "Surrender and Safekeeping of Inmate Property" dated
9/11/98;

C.

Directive #4018R "Referral of Inmates to Mental Health Services" dated
4/8/99;

D.

Directive #4017R "Inmate Observation Aide Program" dated 8/8/88; And

E.

Rules & Regulations: 7.05.090 - 7.05.200.

ATTACHMENTS
A.

Suicide Watch Report (Form #4521 A);

B.

Mental Health Status Notification and Mental Observation Transfer Form (TNF)
(Form #OD/HS 02, REV 12/10/03);

C.

Suicide Watch Tracking Form (#4521 B); and

D.

State of New York Commissioner of Correction Office of Mental Health
(NYSCOCMH) Form #330

I'
...

~

CORRECTION DEPARTMENT
CITY OF NEW YORK

~.

·,fiiJ··

FORM # OOIHS 02
REV 12/10/03

.

·ti1:

REF: 0/0 # 22/93
OIR.4521

"

MEN.TAL HEALTH STATUS NOTIFICATION AND OBSERVATION TRANSFER FORM (TNF)
TO BE COMPLETED BY MENTAL HEALTH /CLINICAL STAFF
FACILITY

INMATE NAME

I

BOOK & CASE #

DATE

NYSID#

/

/

BAS EDON ACLINIC AL INTE RVIEW THIS DATE, THE FO LLOWING MAR KE D (X) INDICATIONS APPLY:

o
o
o

o

SUICIDAL AND I OR HIGHLY SELF-INJURIOUS

0
0

RECEIVING PSYCHOTROPIC MEDICATION
730 EXAMINATION PENDING

TRANSFER TO:

PSYCHIATRIC PRISON WARD:
DOC FACILITY:
OTHER M.O. HOUSING:

0
0
0

HIGHLY ASSAULTIVE
DEVELOPMENTALLY DISABLED
HISTORY OF VIOLENCE "TOWARDS

BHPW
C-71 MENTAL HEALTH
DORMITORY

o
o
o

o

KCHPW

EHPW

NICADMINISTRATIVE UNIT

o

CELL

EITHER

SPECIAL PRECAUTIONS REQUIRED:

o

CONSTANT SUICIDE WATCH

D GENERAL POPULATION - NO DANGER TO SELF OR OTHERS

o NO TRANSFER REQUIRED, BUT MOVE TO

o

DORMITORY

o

CELL

ADDITIONAL INFORMATION/RECOMMENDATIONS:

INTERVI EWER SIGNATURE

TIME OF INTERVIEW

INTERVIEWER NAME (PRINT)

DATE OF INTERVIEW

HRS.

I

I

TO BE COMPLETED BY DEPARTMENT OF CORRECTION STAFF

TIME OF NOTIFICATION TO DOC:

HRS.

TIME OF NOTIFICATION TO NAMCU:

HRS.
FACILITY

PERSON NOTIFIED
(PRINT NAME & RANK)
PERSON NOTIFIED
(PRINT NAME & RANK)
BED /CELL

HOUSING AREA

TRANSFER LOCATION
PERSON NOTIFIED AT
RECEIVING LOCATION (AS REQUIRED)

PRINT NAME

RAN KfTITLE

SHIELD NO.lI.D.

SUICIDE WATCH TRACKING FORM

(Form # 4521 B, eff. 12/10/03)

Facility:
BoOk & Case
No.

Inmate Name (Last, First)

# of rounds
made by clinician

Date and Time watch
was intiatied

I

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II

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4.

II

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I
I

5.

II

I

I

I

I

I

I

6.

"

I
I

I

I
I

I
I

I
I

I
,

I
.I

I
I

I

I

I
I

2.

II
II

3.

1.

I

Housing Type
(Dorm or Cell)

9.

II
II
II

I

I
I
I

10.

II

I

I

I

I

I

I

11.

II

I

I

I

I

I

I

12.

II

I

I

I

I

I

I

13.

II

I

I

I

I

I

II
II
II
II
II

I
I

I

I

I
I
I
I

I
I
I
I

I
I
I

I
I
I

I

I

I

I

I
I
I
I
I
I

7.

8.

14.

15.

16.

17.

18.

I

I

I
I

Prepared by:
Name

Title

Date

St8IeofNewYork
B. C.
COMMISSION OF CORRECTION
Office d MerUI Heath

Form 330 ADM (ec) WOO)

SUICIDE PREVENTION S.CREENING GUIDELINES
. ~ETAlNEE'S NAME

SEX

NAME OF FACILITY

DATE OF BIRTH

MOST SERIOUS CHARGE{S)

DATE

1---

NAME OF SCREENING OFFtCER

psycNafdc",.,... dfIItttg

.pdtwltH:an:etatloll

.

TM:

YES _ _

E.

,

NO

Check appropriate column for each quesUon

Column

A

YEa

Column
B

.-

NO

General ConvnentslObservations
All -vES"' Responses Require
Note to Document

OBSERVATIONS OF ARRESTINGrrRANSPORTING OFFICI!R
1. Arresting or transpOrting officer believes that detainee may be a suicide risk.
If VESt notify 8upervlsor.
NoF8n'lr

.PERSONAL
DATA
.
..
.
. 2.· Detainee lacks support of family or friends in the community.

FrtINb

3.

De'minee has experienced a significant JoSs within the last six months
(e:g..; loss of job, loss of relationship. death of cloSe family member).

4.

Detainee is very worried about major problems other than legal situation
(e.g.; serious financial or family probJems, a medical condition or fear of losing job).

5.

Detainee's family member or significant othet (spouse, parent, close friend,
has attempted or committed suidde.
..

1ove9

Detainee has history of drug or alcohol abuse. (Note drug and when last used.)
7. Detainee has history of counseling or mental health evaluationJtreatmenl
(Note current psychotropic medications and name of most recent ~t agency.)

6.

8.
--

Detainee expresses extreme embarrassment, shame, or feelings of humiflation
as result of chargelincarceratiOn (oonsider detatnee's posttion In communitY
and shocking nature of crime).
.

9. Detainee is thinking about kIIUng himself.
If YES t noUfy 8upervlsor.
10a. Detainee has previous suicide attempl (Explore method and check for scars.)
- b; Attempt occurred Within Jast month.
11.

Detainee is expressing feelings of hopelessnesS (nothing to look forward to).

12. This is detainee's first InCarceration

in 10ckUpl"J8il

BEHAVIOR/APPEARANCE
13~tainee shows signs of depression (e.g., aying, emotional flatness)•.
14.
15.

D~.nee appears oveTfy anxious, panicked, afraid or angry.
De~e is acting and/or talldng in a strange manner

(e.g., cannot focus attention; hearing or seeing things which are not there)~.
16a. Detainee is apparently under the influence of a~oI or drugs..
b. If .YES. is detainee incoherent, or showing signs of withdrawal or mental illness?
If YES to both a & b, noUfy supervisor.
TOTAL Column A
Officer's Comments I Impressions

ACTION
If total checkS in Column A ~re

8 or more, or any shaded b~x is checked, or if you feel it is necessary, notify supervisor and institute constant watch.

Supervisor Notified:

YES

NO

Constant Supervision Instituted:

YES

NO

Detainee Rererred to Medical/Mental Health:
YES
NO

EMERGENCY

NON.eMERGENCY -

medical

medical

If YES:

. mental health

mental health

..

Signature and Badge- Number of Saeening Officer:
Medical I Mental Health Personnel Actions: (To be completed by medical/ MH staff)

i
Over:

f

Fi:Xm 330 ADM (CC) (1/00) page 2

State of_ New York ,.
COMMISSION'eF CORReCTION
Office of Mental Health

INSTRUCTIONS FOR COMPLETING.
SUICIDE PREVENTION SCREENING GUIDELINES - FORM 330 ADM
GENERAL INFOItMATION

nis recommended that the form be completed in triplicate for all detainees prior to ceH assignment and be distributed as follows:
top copy in detainee's file, second copy to medical or mental health personnel at referral, and the third copy for use according to facility's procedures.
.
Comment Column: AU -YES· respon~s require note to document:
1. information about the detainee that officer feels is relevant and important;
2. information specifically requested in questions;
3. infOrmation regarding detainee's refusal or inabiUty to answer questions.
Detainee's Name: Enter detainee's first and last name and middle initial.
sex: Enter male (m) or femaJe (t).
Date of Birth: Enter month, day and year.
Most Serious Charge(s): Enter the most serious charge or charges (no more than two [2]) from this arrest.
Date: Enter month, day and year form wai completed.
lime: Enter the time of day the fonn was completed.
- Name of Fadlity: Enter name of jaJ1 or lock-up.
Name of Screening Officer. Print name of officer completing form.
Psychiatric Problems During The screening officer should check facility files to determine if the inmate had attempted suicide or was referred for mental health services
Prior Incarceration: during prior incarceration. NOTE: PerSons with a diagnosis of schizophrenia or maJordepf8sslon should be referred Immediately
to mental health 8S they are generally more at risk for suicide than persons with other psychiatric dls~rdel'8.

INSTRUCTiONS FOR ITEMS 1-16
en ral Instructions
CheCk e appropriate YES or NO fOr items 1-16.
If infOml on required to complete these questions is unknown to screening officer, such information should be obtained by asking detainee to answer questions. However,
detainee has the right to refuse to answer.
If detainee refuses to answer questions 2-12, enter RTA (refUsed to answer) in the Comment Column next to each question. In addition, complete the YES or NO boxes
only if information is knOwn to you.
'
. .
If during an otherwise cooperative interview, detainee refuses to answer one or two question: Check YES in the box(es) next to the unanswered question(s) and enter RTA
_in the comment box next to each unanswered question.
' .
If detainee is unable to answer all questions 2-12, enter UTA (unable to answer) in the Comment Column next to each question. AlSo enter reason (e.g., not English
speaking) for not answe!ing these questions in the Comment Column next to Question 2. In addition, complete the YES or NO boxes only if information Is known to you.

Observation of Transporting Officer
ITEM (1)

.

Check YES or NO based upon the written/verbal report of the arrestingftransporting officer or upon the screening fonn completed·by the arresting agency.
If YES, notify superviSor.

NOTE: The following quesUons and .observatlons should not be read word for word but restated In your own words.

Personal Data Questions
ITEM (2)
ITEM (3)
ITEM (4)
ITEM (5)
ITEM (6)
ITEM (7)

ITE;M (8)
ITEM (9)
ITEM (10)
ITEM (11)
ITEM (12)

Family/friends: Check NO if someone other than a lawyer-or bondsman would (1) be willing to post detainee's bail, (2) visit detainee while he/she is incarcer.
ated, or (3) accept a collect call from detainee.
Significant loss: Ask all three components to this question-loss of job, loss of relationship and death of close friend orfamily member.
Worried about problems: Ask about such problems as financial, medical condltion or fear of losing job. Check YES if detainee answers YES to any of these; .
Family/significant other attempted suicide: Significant other is defined as someone who has an important emotional relationship with detainee.
Alcohol or drug history: Check YES if de~;nee has had prior treabnent for alcohoVdrug abuse or if prior arrests were alcoholfdrug related.
HistolY of counseling or mental health evaluationltreatment: Check YES if detainee (1) has ever had psychiatric hospitalization, (2) is currentty on psychotropic medication, or (3) has been in outpatient psychotherapy during past six months. Note current psychotropic medication and name of most recent treat.
ment agency.
Check YES if detainee expresses extreme shame as result of arrestor feels that arrest/detention will cause humiliation to self/significant others.
Suicidal: Check YES if detainee makes suicidal statement or responds YES to direct question, "Are you thinking about kllling yourseJf7- If YES, notify supervisor.
Previous attempt Check YES if detainee states he has attempted suicide. If YES or NO, explore method and note scars. Obtain as much infOnnation as
possible re method and time of a,ttempt.
Hopeless: Check YES if detainee states feeling hopeless, that he has given up, that he feels helpless to make his life better. If YES to both items 10 and 11,
noUfy supervisor.
Criminal History: Ask delainee or check files to detennine if this is detainee's first incarceration.

Behavior/Appearance Observations
YES or NO must atways be checked for each of these items: They are observations made by the screening officer. They are not questions.
ITEM (13)
Depression: Indicators include behavior such as crying, emotional flatness, apathy, lethargy, extreme sadness, unusually slow reactions.
ITEM (14)
Overly anxious, afraid, panicked, or angry: Indicators include behavior such as handwringing, pacing, excessive fidgeting, profuse sweating, cursing, physical
violence, etc.
ITEM (15)
Acting in strange manner: Check YES if you observe unusual behavior or speech such as hallucinations, severe mood swin-gs, disorientation, withdrawal, etc.
If detainee is hearing voloes telling him to harm himself, make an immediate referral to mental health services.
ITEM (16a)
Under influence: Check YES if detainee is apparentty intoxicated on drugs or aloohol.
ITEM (16b)
Incoherence, withdrawal, or mental illness: Means physical withdrawal from substance. If YES to both a & b, notify supervisor.
COMMENTSIIMPRESSIONS: Note any "gut" feelings or general ImpressIon re suicide risk.

SCORING
Count all checks in Column A. Enter total. Notify supervisor if (1) total is 8 or more. (2) any shaded area is checked, (3) if you feel notification is appropriate.

BOOKING OFFICER SIGNATURE AND BADGE NUMBER
. Sign form,and enter badge number.

DISPOSITION
Corrections Personnel;" Supervisor notifieq: check YES or NO. Notification should be made prior to cell assignment.
Note if constant supervision instituted.
Note emergency/non-emergency referral to medical and/or mental health personnel.
Medical/Mental Health Personnel: MedicaUmental health staff ~hould note recommendations and actions taken.

-

THE CITY OF NEW YORK
DEPARTMENT OF CORRECTION

PAGE
lof2

FORM #4521A
EFF. l2!lO/O3

SUICIDE WATCH REPORT

FACILITY:

ORDERED BY:

INMATE:

BOOK & CASE #:

HOUSING AREA: - - - BED/CELL#:

--

"

NYSID#:

HOUSING TYPE:
(e.g., MO,PS,INF, etc.)

CELLO

DORM 0

INSTRUCTIONS:
1. TillS REPORT SHALL BE USED TO MONITOR ALL OF THE INMATE'S ACTIVITIES WHILE ON
CONSTANT OBSERVATION IN THE CUSTODY OF THIS DEPARTMENT.
2. ENTRIES SHALL BE MADE TO INDICATE ALL OF THE INMATE'S MOVEMENT THROUGHOUT
THE DEPARTMENT (I.E., CLINIC, COURT, RECREATION, ETC.).
3. ALL COMPLETED SUICIDE WATCH REPORTS MUST BE SUBMITTED TO THE CONTROL ROOM
OF THE FACILITY IN WHICH THE INMATE IS HOUSED.

Constantly observe the subject inmate and record the location and activity of subject inmate On suicide watch
status at (a minimum of) fifteen (15) minute intervals.
. This report should indicate:
i.
General condition and attitude of the inmate, e.g., appears fine, calm, agitated, etc.
ii.
Inmate activity at the time of inspection, e.g., sleeping, eating;
iii. Any peculiar behavior or unusual actions (e.g. refusing to eat, etc.);
The name, title and time of any mental health staff fnterviewing subject inmate;
iv.
The time that the random search is conducted;
v.
vi.
The time the inmate arrives or returns to the housing area or any other program or location;
vii. During movement any Member of Service assigned to observe the subject inmate other than the officer
originally assigned shall record their name and shield # at that time.
DATE: _1_1- TOUR:
AREA SUPERVISOR:

TIME
0700 Hrs.
0715 Hrs.
0730 Hrs.
0745 Hrs.
0800 Hrs.
0815 Hrs.
0830 Hrs.
0845 Hrs.
0900· Hrs.
0915 Hrs.
0930 Hrs.
0945 Hrs.
1000 Hrs.
1015 Hrs.
1030 fIrs.
1045 fIrs.
1100 Hrs.
1115 fIrs.
1130 Hrs.
1145 Hrs.
1200 Hrs.
1215 Hrs.
1230 Hrs.
1245 fIrs.
1300 fIrs.
1315 Hrs.
1330 Hrs.
1345 fIrs.
1400 fIrs.
1415 fIrs.
1430 fIrs.
1445 Hrs.

OFFICER ASSIGNED:
SH#:

OFFICER'S OBSERVATIONS

SH#:

Is Suicide Smock !Blanket Intact ?

SUPERVISOR

YES 1 NO

CLINICIAN
Name & Title

FACILITY'

INMATE'

Date: _1_1_ Tour: _ _ _ Officer Assigned:
Area Supervisor:
TIME

SH#:

--

OFFICER'S OBSERVATIONS

SH#:

NYSID#'
BOOK & CASE #'
Date: _1_1_ Tour: _ _ _ Officer Assigned:

Is Suicide Smock /Blanket Intact?
YES 1 NO
SUPERVISOR
CLINICIAN

Area Supervisor:
TIME

SH#: - OFFICER'S OBSERVATIONS

SH#:
Is Suicide Smock /Blanket Intact?
YES 1 NO
SUPERVISOR

CLINICIAN
Name & Title

Name & Title

2300 firs.
2315 firs.
2330 firs.
2345 Hrs.
0000 firs.
0015 Hrs.
0030 firs.
0045 Hrs.
0100 Hrs.
0115 Hrs.
0130 Hrs.
0145 firs.
0200 firs.
0215 firs.
0230 firs.
0245 firs.
0300 firs.
0315 firs.
0330 Hrs.
0345 Hrs.
0400 Hrs.
0415 Hrs.
0430 firs.
0445 Hrs.
0500 Hrs.
0515 Hrs.
0530 Hrs.
0545 Hrs.
0600 Hrs.
0615 Hrs.
0630 firs.
0645Hrs.

1500 firs.
1515 firs.
1530 firs.
1545 firs.
1600 firs.
1615 firs.
1630 Hrs.
1645 Hrs.
1700 firs.
1715 firs.
1730 firs.
1745 firs.
1800 firs.
1815 firs.
1830 firs.
1845 firs.
1900 Hrs.
1915 Hrs.
1930 firs.
1945 Hrs.
2000 firs.
2015 Hrs.
2030 Hrs.
2045 firs.
2100 Hrs.
2115 Hrs.
2130 Hrs.
2145 Hrs.
2200 Hrs.
2215 Hrs.
2230 Hrs.
2245 Hrs.
Page 2 on • Suicide Walch Report (Fonn #4S21A)

"-