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IDAHO DEPARTMENT OF CORRECTION <br /> Safety Concern Form <br /> Offender Information <br /> Offender's Name: IDOC #: <br /> Facility: --Select-- <br /> Concern Information <br /> Initiator's Name: <br /> In accordance with standard operating procedure 322.02.01.003, Holds, Cautions, Concerns, <br /> and Considerations: Offender, I am requesting the following safety concern on the above named <br /> offender: <br /> ❑ Offender Conflict <br /> ❑ Self-injurious Behavior or Thoughts <br /> ❑ Staff Conflict (you may need to also submit a Relationship Disclosure Form) <br /> Concern Start Date: Concern End Date: <br /> Comments: <br /> When completed, submit this form to the Offender Placement Group (as identified in the Novell <br /> GroupWise address book). <br /> Offender Placement Group Use Only <br /> Comments (if needed): <br /> CIS data entry completed by: Date: <br /> (Print Name) <br /> Appendix E <br /> 322.02.01.003 <br /> (Appendix last updated 7/14/11 ) <br />