New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 92 - MANUAL OF STANDARDS FOR JUVENILE DETENTION FACILITIES
Appendix A
NEW JERSEY JUVENILE JUSTICE COMMISSION
JUVENILE DETENTION MONITORING UNIT
INCIDENT REPORT
Facility Name: _____________________________ Date: ___________
Person Completing the Form: _________ Phone: ___________________
Type of Incident (fire, escape, attempted suicide, etc): ______________
Date and Time of Incident: ____________________________________
Outside Agencies Involved (police, fire dept., health dept., etc): ______
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DETAILED DESCRIPTION OF INCIDENT: (attach copies of all internal incident reports; copies of outside agency reports when involved; provide names of all individuals involved, including victims, alleged perpetrators, witnesses, etc. Use additional pages if necessary.)
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ADMINISTRATIVE ACTION TAKEN: (e.g., hearings scheduled/held; policies or procedures modified; staff disciplined or terminated, etc.)
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This form is to be utilized to report incidents such as deaths, suicide attempts, and physical suicidal gestures. This form should also be used to report escapes, attempted escapes, alleged sexual assaults by juveniles or staff, fires, outbreaks of contagious disease, group disturbances involving four or more juveniles, any situations that result in injury to juveniles or staff requiring medical attention outside of the facility, substantial damage to the facility, mechanical restraints beyond 30 minutes, and any instances when juveniles are transferred to an adult facility. Deaths, suicide attempts, physical suicidal gestures, fires, escapes, and serious injuries must be reported as soon as practicable, but no later than within 24 hours of the occurrence. All other incidents must be reported within three working days of occurrence.
New Jersey Juvenile Justice Commission
Juvenile Detention Monitoring Unit
PO Box 107
Trenton, New Jersey 08625-0107
Phone: (609) 292-1400
Fax: (609) 292-4620
