- DOC 140106A "ODOC Problem List"
- DOC 140106B "ODOC Progress Note"
- DOC 140106C "ODOC Medication Administration Record"
- DOC 140106D "ODOC Discharge Health Summary"
- DOC 140106E "ODOC Food Services Work Permission Slip"
- DOC 140106F "ODOC Health Care Provider Orders"
Section 14
Table of Contents
- DOC 140107A "Worksheet for Monthly Medical Activity Report"
- DOC 140108A "Authorization for Release of Protected Health Information"
- DOC 140108B "Revocation of Authorization for Release of Protected Health Information"
- DOC 140108H "Accounting Of Disclosure Form"
- DOC 140108I "Acknowledgement of Request for Protected Health Information"
- DOC 140108J "Request for Correction/Amendment of Protected Health Information"
- DOC 140111A "Inmate Death Report"
- DOC 140111B "Authorization for Cremation and Disposition"
- DOC 140111C "ODOC Certificate of Death Information Report"
DOC 140112A “Glucometer Quality Control Record”
DOC 140112B “Monthly Oxygen Tank Inspection Log”
- DOC 140113A "Medical Transfer Summary"
- DOC 140113B "Intra-System Transfer Health Screening"
- DOC 140113C "Individual Health Activity Profile (IHAP)"
- DOC 140113E "Medical Transfer Request'
- DOC 140113F "Mental Health Transfer Request"
- DOC 140113G "Mental Health Recommendations for Lower Security"
- Attachment A "IHAP Facility Recommendation Decision Matrix"
- Attachment B "Medical Acuity Reference Guide"
- Attachment C "Specialized Medial Units/Beds"
- DOC 140114A "Medical/Mental Health Screening"
- DOC 140114C "Initial Intake and Routine Physical Examination"
- Attachment A "Initial Physical Examination and Laboratory Requirements: Male"
- Attachment B "Initial Physical Examination and Laboratory Requirements: Female"
- Attachment A "Periodic Physical Examination and Laboratory Requirements Male and Physical Examination and Laboratory Requirements for Inmates Returning from GPS Males"
- Attachment B "Periodic Physical Examination and Laboratory Requirements Female and Physical Examination and Laboratory Requirements for Inmates Returning from GPS Females"
- DOC 140116A "Employee Medical Screening Form"
- DOC 140116B "Medical Clearance for Respirator Use"
- OSHA Respirator Medical Evaluation Questionnaire
- DOC 140117A "Request for Medical Services" English • Spanish
- DOC 140117B "Sick Call Log"
- DOC 140117C "Fecal Occult Blood Testing Education/Acceptance Waiver"
- DOC 140117D "Waiver of Treatment/Evaluation" English • Spanish
- DOC 140117E "Agreement to Attend Outside Specialty Appointment"
- Attachment A "Medications Exempted from $4.00 per Medication Co-Pay "
- Attachment B "Medical Orientation" English • Spanish
- DOC 140118A "Daily/Monthly AED/Narcan Inspection Log"
- Attachment A "Non-Medical Facility Staff Administration and Access to Naloxone (Narcan)"
- Attachment B "Probation and Parole Officer (PPO) and Office of Inspector General (OIG) Agent Administration and Access to Naloxone (Narcan)"
- DOC 140119A "Infirmary Log"
- DOC 140119B "Infirmary Health Care Plan"
- DOC 140119C "Infirmary Discharge Summary"
- DOC 140119D "Infirmary/Convalescent H & P Admission Assessment"
- Attachment A "Infirmary Checklist"
- DOC 140121A "Outside Referral Record Summary"
- DOC 140121B "Health Care Leave Request"
- DOC 140121C "Rules for Health Care Leave and Medication for Inmates Assigned to Community Corrections"
- DOC 140121D "Affidavit for Financial Responsibility for Medical. Mental Health, Dental and/or Vision Care"
- DOC 140121E "Record of Treatment by Community Health Care Provider"
- DOC 140121F "After Clinic Hours-Transfer to Local/OUMC Hospital"
- DOC 140121G "After Clinic Hours-Transfer to ER Note"
- DOC 140124A "Initial Exam"
- DOC 140124B "Dental Plaque Index"
- DOC 140124C "Dental Treatment Plan"
- DOC 140124D “Periodontal Charting”
- DOC 140124E “Review for Partial Dentures”
- DOC 140124F “Endodontic and Orthodontic Consent”
- DOC 140124G “Request for Dental Exception”
- Attachment A "Decontamination Handbook for Bloodborne Pathogens"
- DOC 140125A "Report of Injury or Unusual Occurrence/Encounter"
- DOC 140125B "HIV Inmate Roster Review Log"
- DOC 140125C "Hepatitis B Vaccine Declination Form"
- DOC 140127A "Mental Health Unit, Intermediate Housing Care Unit or Habilitation Program Referral Form"
- DOC 140127B "Evaluation Summary"
DOC 140127C “Oklahoma Department of Corrections Mental Health Unit Intake”
- DOC 140129A "Suicide Watch Log"
- DOC 140129B "Risk Management Interview Worksheet"
- DOC 140129C "Suicide Watch List"
- DOC 140129D "Suicide Watch Conditions/Precautions"
- Attachment A "Psychological Autopsy"
- DOC 140130A "Stock Order Form"
- DOC 140130B "DOC Practitioner Cards Inventory and Reorder Form"
- DOC 140130C "Monthly Stock Inventory Form"
- DOC 140130D "Non-Formulary Medication Request Form"
- DOC 140130E "Pharmaceutical Return Sheet"
- DOC 140130G "Controlled Drug Stock Inventory Order Form Schedule III-V Only"
- DOC 140130H "Medication Error Reporting Form"
- DOC 140130J "Community Corrections Supervised Medication/Syringe Count Log or Supervised TDU Medication Log"
- DOC 140130K "Suspected Adverse Drug Reaction (ADR) Reporting Form"
- DOC 140130L "Barcode Medication Refill Form"
- DOC 140130M "Medication Refill Slip (Split form)"
- DOC 140130N "Medication Refill Slip (Single Form)"
- Attachment A "Approved Canteen OTC Medications"
- Attachment C "KOP vs. Pill Line by Security Level"
- DOC 140132A "Refrigerator/Room Temperature Log"
- DOC 140132B "Radiographic Report"
- DOC 140132C "Optometric Service Record"
- DOC 140133A "ODOC Orthoses, Prostheses and Other Aids to Impairment Appliance Record"
- Attachment A "Severity Classification of Common Chronic Illness"
- Attachment B "Chronic Illness Management Guidelines-Routine and Annual Treatment Guidelines"
- DOC 140137A " Chronic Clinic and/or Routine/Physical Examination"
- DOC 140137B " RN/LPN Chronic Clinic Note"
- DOC 140138A “ODOC Living Will/Advance Directive for Health Care”
- DOC 140138B “ODOC Notification of Activation for a Living Will/Advance Directive and/or DNR”
- DOC 140138C “ODOC Do Not Resuscitate (DNR) Consent Form”
- Attachment A "Mental Health Administration and Organization"
- Attachment A "Procedures for Mental Health Four/Five Point Restraints"
- DOC 140141A "Authorization for Application of Therapeutic Four/Five Point Restraints”
- DOC 140141B "Restraint Medical Flow sheet”
- DOC 140141C "Physical Restraint Log "
- DOC 140141D “Certification Checklist for Safe/Therapeutic Seclusion/Restraint Cell”
- DOC 140141E "Therapeutic Seclusion Watch Log"
- DOC 140141F "Therapeutic Seclusion Conditions/Precautions"
- Attachment A "Peer Review Criteria for Medical Healthcare Provider"
- Attachment B "Peer Review Criteria for Qualified Mental Health Professional"
- Attachment C "Peer Review Criteria for Dentist"
- Attachment D "Peer Review Criteria for Dental Hygienist"
- DOC 140143A "Notification of Medication Adherence"
- Attachment A "Edmonton Symptom Assessment Graph"
- Attachment B "Edmonton Symptom Assessment System Numerical Scale"
- Attachment C "Inmate Volunteer Agreement"
- Attachment D "Consent for Palliative Care"
- Attachment A "Male to Female (MtF) Hormone Therapy Risk and Information Form"
- Attachment B "Female to Male (FtM) Hormone Therapy Risk and Information Form"
- Attachment C "Request for Gender Dysphoria (GD) Evaluation/Treatment Algorithm"
- DOC 140147A “Referral for Gender Associated Requests”
- Attachment B "Mental Health Service Levels Classification System Criteria"
- DOC 140201A "Mental Health or Mental Status Review"
- DOC 140201B “Mental Health Assessment for Special Management/Restrictive/Extended Restrictive Housing”
- DOC 140201C "Abnormal Involuntary Movement Scale (AIMS)"
- DOC 140201D "Facility Mental Health Needs Assessment and Strategic Plan Format"
- Attachment A "Sputum Collection"
- DOC 140301A "Airborne Infection Isolation Room Checklist"
- DOC 140301B "Tuberculosis and Immunization History Record"
- DOC 140301C "Tuberculosis Summary Record"
- DOC 140301D "Tuberculosis Questionnaire"
- DOC 140301E "Preventative Therapy Waiver for Tuberculosis (TB) Infection"
- DOC 140301F "Annual TB Summary Form"
- DOC 140301G "RMP/EMB/PZA Tuberculosis Medication Regimen and Documentation"
- DOC 140301H "INH/B6 Tuberculosis Medication Regimen and Documentation"
- DOC 140652A "Involuntary Medication Report"
- DOC 140652B "Notice of Hearing to Consider Recommendation of Involuntary Administration of Psychotropic Medication"
- DOC 140652C "Medication Review Committee Report"
- DOC 140652D "Involuntary Medication Hearing - Staff Representative Fact Sheet"
- DOC 140652E "Involuntary Medication Appeal Request"
- DOC 140652F "Involuntary Medication Appeal Decision"
- DOC 140701A "Consent for Medical, Dental and Mental Health Treatment"
- DOC 140701B "Vaccine Administration Consent/Refusal Form"
- DOC 140701C "Informed Consent (Neuroleptics)"
- DOC 140701D "Informed Consent for Telemedicine Services"
- DOC 140701E "Consent for Pain Treatment with Controlled Substances: Inmate Agreement"
- DOC 140701F "Consent for Dental Treatment" English • Spanish
Last Modified on
Apr 18, 2025
