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UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) <br />Was the LISMS notified of all incidents involving USMS prisoners? <br />r Yes r No <br />Incidents Not Reported (Contraband, Suicide, Suicide Attempt, Escapes, Escapes Attempts, Physical Assaults on <br />Prisoners, Physical Assault on Staff, Health Care Grievances, Natural Death, Sexual Assault on Prisoners, Sexual <br />Assault on Staff, Homicides, Riots/Distributions, Overdoses, Use of Force). (if needed, use "Other Notes Section" on <br />last page to document more than one incident.) <br />Incident Type Use Incident tyees listed above) Incident Subty e (Leave blank Date of Incident <br />Incident Type Use Incident types listed above) Incident Subtype (Leave blank Date of Incident <br />Remarks <br />Incident Type Use Incident types listed above) Incident Subtype (Leave blank) Date of Incident <br />I I I I - - I <br />Remarks <br />Incident Type Use Incident types listed above) IncidStpe Leave blank Datnt <br />Incident Type Use Incident types listed above Incident Subtype (Leave blank) Date of Incident <br />I I I I I <br />NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information <br />which is for the sole use of the intended reciplent(s). Any unauthorized review, use, disclosure, or distribution is prohibited, If you are not the intended <br />recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used <br />only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be <br />reported as such. <br />UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) <br />Form USM-218 <br />Page 5 of 27 Rev. 02125 <br />