EXTRAORDINARY OCCURRENCE REPORT

EXTRAORDINARY OCCURRENCE REPORT
Email Completed Report To: JailReport.EOR@ky.gov
Reporting Facility
Reporting Official
Title
Date of Report

MonthDayYear
Date
Date/Time Of Occurrence

MonthDayYear
Date
Inmate Name
Inmate Type

StateCountyFederal
DOC # or SSN #
Date of Birth

MonthDayYear
Date
Race
Booking Date

MonthDayYear
Date
Type of Extraordinary Occurrence (Select Applicable Items)

EscapeAssaultContrabandDeathSexually Abusive ConductSelf-InjryAccidentDisease OccurrenceAttempted EscapeRiotFireEscapee ApprehendedAttempted SuicideOther
Names and DOC# or SSN of Other Inmates Involved In Occurrence
1
2
3
Names of Witnesses to Occurrence
1
2
3
Names of Staff Involved in Occurrence
1
2
3

If Death, then:

Rows	Yes	No
Did decedent exhibit signs of illness prior to death
Was decedent examined by a physician prior to death?
Coroner Notified?
Postmortem exam conducted or scheduled to be conducted?

Type a question

Signature of Reporting Official
Title
*Attach PREA Forms
Location of Occurrence
Describe the extraordinary occurrence in detail Include such items as whowhenwhatetcPleaseprovide any and all supportir documentation Or attach all Incident reports Statements Investigations ETC
Should be Empty:

Names and DOC# or SSN of Other Inmates Involved In Occurrence