Detainee Wellness Check Log Form
Record a routine detainee wellness check using the same title consistently throughout the form. This form is for operational logging only and does not imply suitability for sensitive medical information.
Log Entry Details
Wellness Check Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Wellness Check Time
*
Hour Minutes
AM
PM
AM/PM Option
Facility / Location or Housing Unit
*
Checking Officer / Staff Name or ID
*
Detainee Identification
Detainee Name
*
First Name
Middle Name
Last Name
Booking / Reference Number
*
Cell / Block / Housing Location
*
Wellness Check Record
Observed general condition
*
No concerns observed
Minor concern noted
Urgent concern noted
Temperature / appearance / alertness notes
Follow-up needed?
*
Yes
No
Follow-up details
Submit
Should be Empty: