Referral of Incident for Contract Employees (Internal Affairs)

• Legal Form Number: BP-A0774
• Date: 2010-06
• Year: 2010
• Section: Federal Bureau of Prisons

REFERRAL OF INCIDENT FOR CONTRACT EMPLOYEE (INTERNAL AFFAIRS)

U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A0774

JUN 10

OIA FAX: (202) 514-8625 DENVER FIELD OFFICE FAX: (303) 365-4445

FTS 368-8625 TELEPHONE: (303) 365-4400

Allegation(s)

Subject of Incident's Information:

SUMMARY OF INCIDENT: (Provide brief, but complete summation of incident including names of any witnesses)

Describe any action taken locally prior to OIA referral: Are local, state or federal authorities involved?

Time of Incident Date of Incident

Place of Incident Occurred:

Classification 3 Case____ NO____ YES

Printed Name and Signature of Person Preparing Referral of Incident

Date Location CEO Printed Name and Signature

(In Preparation of Telephonic Report)

Source of Allegation(s)

TitleFull Name

Social Security No.Date of Birth

Victim (Inmate) Information (If applicable):

Title/Reg. No.Full Name

NOTE: Please fax all pertinent information as soon as possible after completion of the telephonic referral.

Include all statements, memos, affidavits, medical reports, personnel actions as may apply.

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