Inmate Disciplinary Report Form
Use this form to document inmate disciplinary incidents, staff observations, involved parties, evidence, actions taken, and supervisor review.
Incident Details
Incident Date
*
-
Month
-
Day
Year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Incident Location Within Facility
Incident Type / Category
Rule Violation
Fight
Contraband
Refusal to Comply
Property Damage
Intimidation
Disobeying Orders
Other
Incident Description / Narrative
*
Reporting Staff Information
Reporting Staff Name
*
First Name
Middle Name
Last Name
Staff Role / Title / Post Assignment
*
Please Select
Officer
Sergeant
Lieutenant
Captain
Correctional Counselor
Nurse
Other
Staff ID / Employee Number
Work Extension / Phone
Report Basis
*
Firsthand
Witness-based
Both
Involved Inmate Information
Inmate Name or Facility Identifier
*
Housing Unit / Block
*
Please Select
Unit A
Unit B
Unit C
Unit D
Segregation
Medical Housing
Other
Inmate Status at Time of Incident
*
Assigned Cell
Recreation
Transport
Dining
Work Detail
Medical Area
Other
Co-Involved Inmate Names / Identifiers
Rule Violation and Behavior
Rule Violated / Misconduct Category
*
Please Select
Insubordination
Contraband Possession
Unauthorized Movement
Assault/Threats
Property Damage
Disruptive Behavior
Refusal to Comply
Other
Behavior Observed
*
Verbal Refusal
Physical Aggression
Possession of Contraband
Unauthorized Movement
Damage to Property
Threats
Disruptive Behavior
Other
Were Orders Given and Obeyed?
*
Yes
No
Partially
Inmate Response / Statements
Witnesses and Staff Involved
Witnesses
Staff Involved in Response
Uninvolved Witnesses or Camera Presence
*
Witnesses present
Camera footage available
Both
Neither
Camera Footage Location / Reference Note
Injuries, Property Damage, and Evidence
Any injuries occurred?
*
Yes
No
Injury description
Any property damage occurred?
*
Yes
No
Property damage description
Evidence collected or attached
Photos
Incident log
Seized contraband
Video reference
Other
Evidence storage location or reference number
Immediate Response and Actions Taken
Actions Taken by Staff
*
Verbal warning
Separated inmates
Used restraint
Medical referral
Search conducted
Contraband seized
Notified supervisor
Referred to custody review
Other
Were emergency services or medical staff contacted?
*
Yes
No
Immediate response details
*
De-escalation steps taken
Supervisor Review and Disposition
Supervisor Name
*
First Name
Last Name
Review Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Preliminary Determination / Disposition
*
No Action
Warning Issued
Report Forwarded
Disciplinary Hearing Required
Segregation Recommended
Loss of Privileges Recommended
Other
Follow-up Actions Required
Notify Inmate
Notify Security Staff
Schedule Hearing
Collect Additional Statements
Document in File
Other
Supervisor Comments
Attachments and Final Submission
Supporting Attachments
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Final Submission Confirmation
*
I confirm the report is complete and accurate
Submit Report
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