FLORIDA MODEL JAIL STANDARDSANNUAL MEDICAL INSPECTION REPORT

Part IName of Facility:      Facility Type:      Mailing Address:      City:       County:       Phone:      Agency Head:      Facility Administrator:      Chairperson – County Commission:      Chairperson or Mayor – City Council:      

Inspection Date:

     

Facility Population on Date of Inspection:      

Date of Last Inspection:      Health Services Provided By: Agency Staff: Contracted: If Provided By Contract, Company Name:      Health Services Administrator:      Medical Inspector(s) and Agency:

1.      2.      3.      4.      5.      6.      7.      8.      9.      

* Part I to be completed by the agency and provided to the Inspector(s) on the day of inspection.

FLORIDA MODEL JAIL STANDARDSANNUAL MEDICAL INSPECTION REPORT

Part I

Health Services Staff:

Full Time Part Time Total

Physicians                  ARPN/PA                  RN                  LPN                  CNA/MA/EMT                  All Other Staff                  

Additional Information:      

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