5-10 7 INCIDENT STATEMENT I Facility 39292151411! 33,949,; I Incident Number I I [Incident Date 545-47 Incident Time (HRS) (9066M I Person Name ID Number Person Type Person Role ., (Employees#/lnmate #ICivilian ID) (EmployeellnmateICivilian) or Partic?nt) (Jim! ?Ihl Pom [Housing Location (Far Inmates/Residents only): I I I I Based Whatdid receive uries.? I We?resyou evaluatedI-be?medical? I I Printed Name . 55:51,, Wire! Signature Date; 5 1? - ThIs sectIon to be completed by staff if the or Inmate/reSIdent refused to complete the 5- 1Q Place an in the appropriate box: Inmate/Resident refused to complete this Civilian/Other?re?fused 'to complete this 5-.1C ;_EmployeeIWltness Printed Name I Date: I 'EmployeeIWItness SIgnature Employee/WItnessPrinted-Name I Dateezil E-thiployeeIWitHSSisSign?f?f?w Page 1 of 1 Proprietary Information - Not For Distribution - Copyrighted - Property of CoreCivic 5-1C INCIDENT STATEMENT lggagac?ityu Ste 'De-?m?ii?mh 039W I?Incident Number ~31 I Iii-rln?oide?tDate- AI 5 I 1?5 I Irlncident I . 7:5 Person Name ID Number Person Type 1 #lCIviIian ID) (Employee/Inmat?ilCivilian) I VMAUJ A. use, I 119110334 'Poc?t?xuc?xm?i lj'Housing Location; (For?ylnmate?isesidfentsr Only) I I ?and do? 7 receive ?rie's? I I PrintedName 2-7;th cf, ?my $9 Date: 545-17 Date: by?oreciyic staff if the civilianlotheror. 16 Place an in the appropriate box: InmaltelRe?idjent1refused toIcomplete'this 5-1C 'CiViIi?h/Oi??fif?qued I to, complete, 'th is 5-1 i5?mRI9YeelWitness Printed Name pat?; I I Data Page 1 of 1 10/3113 Proprietary Information - Not For Distribution - Copyrighted - Property of CoreCivic 5-1 INCIDENT STATEMENT emu/I I Incident Number I 200 - - 3: I Incident DateIncident Time (HRS) I OOQS I Person Name 7. . ID Number '1 Person Type ,v Person Role I :g . 6 (Employee #linniate ID) (Employee/lnmat?lCiVilIan) (Witness or PartICIpant) moth. IIJIM mo 23 c/ ?m??a?rte mew I I Housing-Location (For. InmatesIResidents Only) I I A YES chub; I gsl?rinted Name: frea?d (4 1- . wit/<5 Date: 5.43.77 .. Abate: This sectiontelbepohuil?ted(by Q?riecwic staffif the'ciVilianIother or inmate/residentrefused to completeithe 54. 194 Place an in the appropriate box: Inmate/Resident refused, to: complete this 5-1C this 2? 1? -, Ein?lqveelwitnessPrintedName mate: I EmployeelWitness Printed Name Date: I Employeellivitn'ess Signature Page 1 of 1 10I3I13 Proprietary Information - Not For Distribution - Copyrighted - Property of CoreCivic