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IDAHO DEPARTMENT OF CORRECTION <br /> Medical Consideration Request Form <br /> Offender Information <br /> Offender's Name: IDOC #: <br /> Facility: --Select-- <br /> Consideration 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 medical consideration on the above <br /> named offender: <br /> ® Cane ❑ Lower Level or Tier <br /> ❑ Cotton Blanket ❑ Oxygen Dependant <br /> ❑ Crutches ❑ Vision Impaired <br /> rJ Gym or Recreation Restriction ❑ Walker <br /> ❑ Handicap Access Required ❑ Wheelchair <br /> ❑ Hearing Impaired ❑ Other (written justification is required for this selection) <br /> ❑ Lower Bunk <br /> Consideration Start Date: Consideration End Date: <br /> Comments: <br /> When completed, email this form to the designated healthcare services staff per SOP <br /> 322.02.01.003. <br /> Designated Healthcare Services Staff Use Only <br /> Comments (if needed): <br /> CIS data entry completed by: Date: <br /> (Print Name) <br /> Appendix F <br /> 322.02.01.003 <br /> (Appendix last updated 7/14/11 ) <br />