RFP10858_Exhibit_4_MedicalClearance_Form.pdf

Probation Medical and Mental Health Clearance Form

63D-8.001 and 63D-11.004, F.A.C./63M-2 Form HS 051 Rev. July 2010

THIS FORM MUST BE COMPLETED PRIOR TO THE YOUTH

BEING ACCEPTED FOR DETENTION SCREENING

Youth’s Name: __________________________________________ DOB: _______________________

Today’s Date: _________________ Arresting Agency: ____________________________________

PART 1 SERIOUS PHYSICAL CONDITION: F.S. 985.115(2)(c) requires that instead of the department accepting a youth suffering from a physical condition who appears to be in need of prompt diagnosis or prompt treatment the youth must be released to a law enforcement officer who shall deliver the youth to a hospital for necessary evaluation and treatment. The answers to questions 2 through 13 will help the screener comply with this sub-paragraph of the statute but may not automatically require medical screening.

NOTE: THE PRESENTING OFFICER MUST NOT DEPART UNTIL THIS FORM HAS BEEN COMPLETED IN

ITS ENTIRETY AND THE YOUTH HAS BEEN ACCEPTED FOR ADMISSION INTO THE JAC.

The following questions must be asked of the presenting law enforcement officer:

1. Has an electronic stun gun (such as a taser) been used on this youth? No Yes If yes please check the appropriate boxes describing the youth’s condition

Unconsciousness Seizure Activity Delirium Paralysis Confusion Shortness of Breath Memory Loss Chest pain Other: (Please describe) _____________________________________________________________

A check in any of the above boxes will require medical clearance by a licensed health care professional.

The next series of questions will be asked of the youth:

2. Do you have any open wounds or injuries? No Yes, explain: ______________________________

3. Do you have any serious medical problems or illnesses that require prompt/immediate medical attention?

No Yes, explain: _________________________________________________________________

4. Do you have any health complaints such as sickness or pain at the present time?

No Yes, explain:__________________________________________________________________

PROBATION MEDICAL AND MENTAL HEALTH CLEARANCE FORM

63D-8.001 and 63D-11.004, F.A.C./63M-2 Form HS 051 Rev. July 2010

5. Do you have any of the following health problems?

Diabetes Seizures Cancer Asthma Heart problems Tuberculosis Sickle cell disease High blood pressure Kidney Disease requiring Head Injury within past 24 hours Dialysis Other, Explain:

6. Are you taking any of the following medications? If yes, provide the name(s), the last time you took a dose, and the time that the next dose is due, in the space below.

Seizure medication Asthma medication Heart medication Psychotropic medication Blood pressure medication Diabetes medication (NOT

Insulin) Time of last dose: AM PM

Time next dose is due: AM PM

7. Are you taking insulin? No Yes If YES, does the youth report or demonstrate any of the following signs or symptoms?

Headache Dizziness Confusion Pale, Cool or Clammy Skin Increased Hunger/Thirst Abnormal Behavior Rapid Heart Rate/Tachycardia Shallow Respirations/Breathing

A check in any box in Item 7 will require medical clearance by a licensed health care professional.

8. Are you taking any other medication(s) not listed above, if so please provide the name(s) and times that the next dose is due?

Medication: Time next dose due: AM PM

The following series of questions will be answered by the screener from his or her observations of the youth.

9. Youth has an obvious injury (refer to question 2) No Yes, if yes explain:

63D-8.001 and 63D-11.004, F.A.C./63M-2 Form HS 051 Rev. July 2010

10. Youth appears ill No Yes, if yes explain:

11. Youth has difficulty moving No Yes, if yes explain:

12. Youth has visible abrasions, cuts or bruises No Yes, if yes explain:

13. Female youth only:

Youth is pregnant? No Yes Pregnancy Suspected

PART 2 MENTAL ILLNESS: F.S. 985.115(2)(d) requires that instead of the department accepting a youth who appears to be mentally ill as defined in 394.463(1) or who has threatened, attempted, or inflicted physical harm on him or herself or others due to mental illness, the youth must be released to a law enforcement officer who shall deliver the youth to a designated public receiving facility as defined in s. 394.455 for examination under s. 394.463. The answers to question 14 through 22 will help the screener comply with this sub-paragraph of the statute.

The following question must be asked of the presenting law enforcement officer:

14. Do you have reason to believe that this youth has a mental illness and because of his or her mental illness has refused voluntary examination or is unable to determine whether examination is necessary?

No Yes If, yes please explain.

15. Does the youth appear to be incapacitated as a result of mental illness? No Yes, explain:

16. Has this youth tried to kill himself/herself recently? No Yes, Please explain and list the date(s):

63D-8.001 and 63D-11.004, F.A.C./63M-2 Form HS 051 Rev. July 2010

17. Do you have reason to believe that there is a substantial likelihood that without care or treatment the youth will cause serious bodily harm to himself/herself or others in the near future, as evidenced by recent behavior?

No Yes, if yes explain:

The following questions will be answered by the screener from his or her observations of the youth.

18. Does the youth appear to be incapacitated as a result of mental illness? No Yes, explain:

19. Has the youth threatened, attempted or inflicted physical harm on self or others due to mental illness? No

Yes, explain:

The following questions must be asked of the youth:

20. Have you tried to kill yourself in the last 24 hours? No Yes, explain:

When? ___________________________________________________________________________________

How? ____________________________________________________________________________________

21. Are you thinking about killing yourself now? No Yes, explain:

22. Would you kill yourself if you had the chance? No Yes

A YES answer to any question between 14 and 22 above AND presence of any ONE of the behavioral symptoms below requires that the law enforcement officer must transport the youth to a mental health receiving facility prior to screening.

Youth is extremely upset or distressed Youth appears depressed (sad) Youth has a plan for suicide Youth reports hopelessness (negative thoughts Youth’s suicide plan is feasible about future/nothing to live for) Youth appears determined to kill himself/herself Youth reports a mental health diagnosis (e.g., Youth’s past suicide attempt was serious depression, anxiety, ADHD, alcoholism, etc.)

(attempt caused injury or hospitalization) Youth reports history of mental health counseling Youth knows someone who committed suicide Youth reports relationship problems recently

63D-8.001 and 63D-11.004, F.A.C./63M-2 Form HS 051 Rev. July 2010

The youth must remain on one-to-one supervision while awaiting transportation by law enforcement to a mental health receiving facility. One-to-one supervision refers to the supervision of one youth by one staff member who remains within five feet of the youth at all times.

PART 3 INCAPACITATED: F.S. 985.115(2)(e) requires that instead of the department accepting a youth who appears incapacitated by substance use, the youth must be released to the law enforcement officer who shall deliver the youth to a hospital, addictions receiving facility, or treatment resource center. The answers to questions 23 and 24 will help the screener comply with this sub-paragraph.

The following question must be asked of the youth:

23. Have you used drugs or alcohol in the last 24 hours? No Yes, explain which drugs and how much:

Which Drug(s) and/or Alcohol: How Much:

1.

2.

3.

4.

5.

6.

7.

The following series of questions will be answered by the screener from his or her observations of the youth:

24. Does the youth appear to be incapacitated as a result of substance abuse? No Yes, explain:

A YES answer requires medical clearance by a licensed health care professional.

63D-8.001 and 63D-11.004, F.A.C./63M-2 Form HS 051 Rev. July 2010

PART 4 YOUTH DISPOSITION BASED ON SCREENING PROCESS: Note the status of the youth’s acceptance for screening or referral for medical clearance prior to screening.

25. Youth Disposition Based on Screening Process (Please check one):

Transfer to hospital or local receiving facility by law enforcement officer for clearance

EMS must be summoned immediately by calling 911

Accepted for Screening as a priority

Accepted for Screening, but requires call to parent or guardian

Accepted for standard Screening

Please document any refusals to answer questions by youth or notification of supervisor(s), with details:

Staff Signature Printed Name

Title Date and Time

THIS FORM SHALL BE PROVIDED TO THE FACILITY WHERE THE YOUTH IS NEXT RELEASED

(SUCH AS DETENTION CENTER, SHELTER). THIS FORM MAY ALSO BE RELEASED TO THE

PARENT OR GUARDIAN UPON REQUEST OR WHEN THERE IS A NEED FOR FOLLOW UP.