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UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) <br />Does the facility ensure TS testing during the initial intake process? <br />C Yes C No <br />If 'No', how long after intake does the TB test occur? <br />months FI days <br />Are TB test results provided to the U SMS within 14 days? <br />C" Yes C No <br />If'Nd, when were results provided? <br />months U days <br />Do all prisoners undergo mental health screening during the initial intake process? <br />C Yes (" No <br />If 'No', how long after intake does the mental health screening occur? <br />months days <br />Do all prisoners undergo dental health screening within 14-days after the initial intake process? <br />C Yes C No <br />If 'No', how long after intake does the dental health screening occur? <br />months days <br />Are all comprehensive medical screening results reviewed by a physician? <br />C Yes C No <br />If Yes, how long after intake does this occur? <br />months days <br />Is a comprehensive health appraisal for each prisoner completed within 14-days after initial intake? <br />C Yes f No <br />If 'No', how long after intake does the appraisal occur? <br />months = days <br />Are intake medical screening records maintained for every prisoner? <br />C Yes C No <br />Medical, Dental, and Mental Health <br />Does the facility have a medical unit staffed 24/7? <br />C Yes C No <br />Does the facility employ an on -site mental health professional? <br />C Yes (" No <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 recipiengs). 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 />UNCLASSIFIEDHLAW ENFORCEMENT SENSITIVE (When Completed) <br />Form U SM-21 S <br />Page 12 of 27 Rev. 02125 <br />