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UNCLASSIFIEDILAW ENFORCEMENT SENSITIVE (When Completed) <br />Medical Staff lnformation (Annotate number of authorized and filled positions per facili$'s staffing plan) <br />Authorized Filled <br />Physician <br />Physician's Assistant <br />Nurse Practitioner <br />Registered Nurce <br />Licensed Practical Nurse <br />Mental Health Professional <br />Other Medical Staff <br />Contraband <br />List facility's total number of contraband incidents since last USMS DFR (if app licable). <br />orAlcohol <br />Electronic Device <br />orAlcohol Electronic Devices <br />Tool <br />lncidents <br />List facility's total number of incidents since last USMS DFR (if applicable). <br />Suicides Suicide <br />Assaults on Prisoners Assaults on Staff <br />Health Care Grievances NaturalDeaths Sexual Assaults on Prisoners <br />Sexual Assaults on Staff Riots/Disturbances <br />Overdose Deaths Overdoses Use of Force Excessive Use of Force <br />NOTTCE: This document is intended FOR OFF|C|AL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information <br />which is tor the sole use of the intended rccipient(s). Any unauthorized revieu use, disclosure, or distribution is prohibiled. lf you are not the lntended <br />ieJpient, please contact the sender and clesiroy ati copies of this document. Any Protected Health lnformation conlained in this document is to be used <br />onifio iidfn p.viding healthcare seMces to ferteral prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be <br />reported as such. <br />UNCLASSIFIED//LAW ENFORCEMENT SENSITIVE (When Completed) <br />Form USM-218 <br />Page 3 ot 22 Rev.07t21