EFTA00131259

## Attachment 2 -

## DUTY OFFICER INCIDENT REPORT

<table border="1"><tr><td>DATE:</td><td>DUTY OFFICER:</td><td>LOCATION:</td><td></td></tr><tr><td>CALLER:</td><td>LOCATION:</td><td>TIME:</td><td></td></tr><tr><td>INCIDENT:</td><td>INSTITUTION:</td><td>TIME:</td><td></td></tr><tr><td colspan="3">PERSON(S) NOTIFIED:</td><td></td></tr></table>

PERSON(S) NOTIFIED:

<table border="1"><tr><td></td><td>OFFENDER #1</td><td>OFFENDER #2</td><td>OFFENDER #3</td></tr><tr><td>NAME</td><td></td><td></td><td></td></tr><tr><td>SENTENCE LENGTH</td><td></td><td></td><td></td></tr><tr><td>RELEASE DATES</td><td></td><td></td><td></td></tr><tr><td>REG.NUMBER</td><td></td><td></td><td></td></tr><tr><td>AGE</td><td></td><td></td><td></td></tr><tr><td>OFFENSE</td><td></td><td></td><td></td></tr><tr><td>SL/CUSTODY</td><td></td><td></td><td></td></tr><tr><td>CIM STATUS</td><td></td><td></td><td></td></tr></table>

SUMMARY OF THE INCIDENT:
*If known, indicate if incident was gang or racial related.

<table border="1"><tr><td colspan="2">Complete and submit form by 8:00 am the following day.</td><td>Incidents of major significance should be immediately reported.</td></tr><tr><td>Distribution: Institution/CEO</td><td>Regional Duty Officer</td><td></td></tr></table>

(CONTINUE ON BACK OF FORM IF NEEDED)

Sensitive But Unclassified