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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 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 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 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"

  • 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 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 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"

  • 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
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