CJ-5B ADDENDUM Survey of Jails in Indian Country CJ-5B ADDENDUM

CJ-5B ADDENDUM
RETURN
TO

OMB No.1121-0094: Approval Expires x/xx/xxxx

Cynthia Helba
Survey of Jails in Indian Country
RA1100
Westat
1650 Research Boulevard
Rockville, MD 20850

CJ-5B ADDENDUM

FORM
(02-23-10)

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT

2011 ANNUAL
SURVEY OF JAILS
IN INDIAN COUNTRY

WESTAT

DATA SUPPLIED BY
NAME

Title

ADDRESS

Number and street or P.O. box/Route

City

TELEPHONE

Area Code

Area Code Number
FAX
NUMBER

Number

State Zip Code

E-MAIL
ADDRESS
PLEASE CORRECT ANY ERROR IN NAME, MAILING ADDRESS, AND ZIP CODE.

•

GENERAL INFORMATION
If you have any questions about completing this form, please contact Cynthia Helba of Westat at 1-888-675-7330
or BJS Statistician, Todd Minton at 202-305-9630.

•

Please mail your completed questionnaire to Westat in the enclosed envelope before July 31, 2011,
or FAX (all) pages to 301-315-5912.

•

Please retain a copy of the completed form for your records.

Burden statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it
displays a currently valid OMB control number. The burden of this collection is estimated to average 30 minutes
per response, including reviewing instructions, searching existing data sources, gathering necessary data,
and completing and reviewing this form. Send comments regarding this burden estimate or any aspect of
this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics,
810 Seventh Street, NW, Washington, DC 20531.

INSTRUCTIONS

•

If the answer to a question is "not available" or "unknown," write "DK" in the space provided.

•

If the answer to a question is "not applicable," write "NA" in the space provided.

•

If the answer to a question is "none" or "zero," write "0" in the space provided.

•

When exact numeric answers are not available, provide estimates and mark (x) in the
box beside each figure that is estimated. For example 1,234 (‡)

FORM CJ-5B ADDENDUM (02-23-10)

21. As a matter of policy, does this facility test inmates
for HEPATITIS B infection?

SECTION III ⎯ INMATE HEALTH

Mark (x) at least one box in each row.
Yes

No

a. At admission . . . . . . . . . . . . . . . . . . . . .

G

G

b. Annually or at regular interval . . . . . . .

G

G

G On-site physicians or other medical

c. Random sample . . . . . . . . . . . . . . . . . .

G

G

3

G Off-site medical services provided by IHS

G

G

4

G Off-site medical services provided by

d. Person with no history of
vaccination . . . . . . . . . . . . . . . . . . . . . .
e. Upon request . . . . . . . . . . . . . . . . . . . . .

G

G

f. Upon clinical indication
of need . . . . . . . . . . . . . . . . . . . . . . . . . .

G

G

g. After possible exposure
to active Hepatitis B . . . . . . . . . . . . . . .

G

G

h. At release . . . . . . . . . . . . . . . . . . . . . . . .

G

G

i.

G

G

18. How does this facility provide health services
to inmates? Mark (x) all that apply.
1

G On-site staff physicians or other medical
employees of the jails

2

services provided by IHS

privately run facilities (e.g., private
practice, hospital, etc.)

5

G Other — Specify

•

19. Does this facility detoxify CONFINED persons from
drugs or alcohol?

•
1

Detox is the managed withdrawal from alcohol or
drugs by medical or other trained professionals.

G Yes — On June 30, 2011, how many inmates

Active Hepatitis B
confirmed by positive
testing of serology

Other — Specify

were being detoxified?

G

Inmates
2

22. As a matter of policy, does this facility test inmates
for HEPATITIS C infection?

G No

Mark (x) at least one box in each row.

20. As a matter of policy, does this facility test inmates
for TUBERCULOSIS infection?
Mark (x) at least one box in each row.

Yes

No

a. At admission . . . . . . . . . . . . . . . . . . . . . .

G

G

b. Annually or at regular interval . . . . . . . .

G

G

c. Random sample . . . . . . . . . . . . . . . . . . .

G

G

d. Person with no history of
vaccination . . . . . . . . . . . . . . . . . . . . . . .

G

G

e. Upon request . . . . . . . . . . . . . . . . . . . . .

G

G

Yes

No

a. At admission . . . . . . . . . . . . . . . . . . .

G

G

b. Annually or at regular interval . . . . .

G

G

c. Random sample . . . . . . . . . . . . . . . . .

G

G

d. Person with no history of
vaccination . . . . . . . . . . . . . . . . . . . .

G

G

e. Upon request . . . . . . . . . . . . . . . . . . .

G

G

f. Upon clinical indication
of need . . . . . . . . . . . . . . . . . . . . . . . . . . .

G

G

f. Upon clinical indication
of need . . . . . . . . . . . . . . . . . . . . . . . .

G

G

g. After possible exposure
to active Hepatitis C . . . . . . . . . . . . . . . .

G

G

h. At release . . . . . . . . . . . . . . . . . . . . . . . . .

G

G

i. Other — Specify

G

G

g. After possible exposure
to active TB disease . . . . . . . . . . . . .

•

•
G

G

Active TB disease, either
confirmed by sputum
culture or suspected with
culture pending

h. At release . . . . . . . . . . . . . . . . . . . . . .

G

G

i.

G

G

Other — Specify

Page 2

Active Hepatitis C
confirmed by positive
testing of anti-HCV

FORM CJ-5B ADDENDUM (02-23-10)

23. As a matter of policy, does this facility screen inmates
for the antibody to the Human Immunodeficiency
Virus (HIV) that causes AIDS?

25. What specific procedures for suicide prevention
does this facility follow?
Mark (x) all that apply.

Mark (x) at least one box in each row.
Yes

No

1

G Assessment of risk at intake

a. At admission . . . . . . . . . . . . . . . . . . . . .

G

G

2

G Staff training in risk assessment/suicide

b. Random sample . . . . . . . . . . . . . . . . . .

G

G

c. Upon request . . . . . . . . . . . . . . . . . . . . .

G

G

d Upon clinical indication
of need . . . . . . . . . . . . . . . . . . . . . . . . . .

G

G

e. Upon involvement in incident . . . . . . .

G

f. At release . . . . . . . . . . . . . . . . . . . . . . . .
g. Other — Specify

prevention

3

G Special inmate counseling or psychiatric
services

4

G

G

5

G Suicide watch cell or special location

G

G

6

G Inmate suicide prevention teams

G

G

7

G Other — Specify

8

G

24. As a matter of policy, does this facility —

Live or remote monitoring of high risk
inmates

None

Mark (x) all that apply.
1

2

SECTION IV ⎯ FACILITY PROGRAMS

G Screen inmates at intake for mental disorders
• EXCLUDE screening for suicide.

26. Between July 1, 2010 and June 30, 2011, what
type of work assignments were available to
persons CONFINED in this facility?

G Conduct psychiatric or psychological evaluation

and assessments (other than at time of intake) to
determine inmate mental health or emotional status

Mark (x) all that apply.
3

G Provide 24-hour mental health care to inmates
either on or off facility grounds

4

1

textiles, manufacturing, services. etc.)

G Provide therapy/counseling by a trained mental

2

health professional on a routine basis

5

psychotropic medications to inmates

6

Drugs having a mind-altering effect
(e.g., antidepresents, stimulants,
sedatives, tranquilizers, and other
anti-psychotic drugs)

G Provide assistance to release inmates to obtain

8

G

G

3

G Farming/agriculture

4

G Public works assignments — inmates work
outside the facility and perform road, park,
or other public maintenance work

community mental health services

7

G Facility support services (e.g., office and
administrative work, food service, building
maintenance, etc.)

G Prescribe, distribute, or monitor the use of
•

G Correctional industries (e.g., wood products,

5

G Other — Specify

6

G None

Other — Specify

Does not provides mental health services to inmates

Page 3

FORM CJ-5B ADDENDUM (02-23-10)

27. Between July 1, 2010 and June 30, 2011, did this
facility provide counseling or special programs
to persons CONFINED in this facility?

NOTES

Mark (x) at least one box in each row.
On
Off
facility facility
No
grounds grounds program
a. Drug dependency/
counseling/awareness . . .

G

G

G

b. Alcohol dependency/
counseling/awareness . . .

G

G

G

c. Sex offender treatment . . .

G

G

G

d. Vocational training . . . . . .

G

G

G

e. Employment . . . . . . . . . . . .
(e.g., job seeking and
interviewing skills)

G

G

G

f. Life skills and community
adjustment (including
personal finance, conflict
resolution, etc.)

G

G

G

g. Domestic violence
counseling . . . . . . . . . . . . .

G

G

G

h. Parenting/child
rearing skills . . . . . . . . . . .

G

G

G

G

G

G

i.

Religious/spiritual
counseling . . . . . . . . . . . . .

28. Between July 1, 2010 and June 30, 2011, what
type of educational programs were offered to
persons confined in this facility?
Mark (x) at least one box in each row.
On
Off
facility
facility
No
grounds grounds program
a. Accredited education . . . .
program (e.g., basic
and high school classes)

G

G

G

b. GED program . . . . . . . . . . .

G

G

G

c. Special education needs
program (e.g., programs
for inmates with learning
disabilities)

G

G

G

d. College level classes . . . .

G

G

G

e. Provide tutors . . . . . . . . . .

G

G

G

Page 4