STATE OF NORTH CAROLINA NOTICE OF RETURN OF ESCAPEE OR CONDITIONAL RELEASE Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Date: ________________ Re: Date of UA: ________________ Facility: __________________________ _____________________________________________ Address:__________________________ ___________________________ (Patient) Last known address: _________________________________ Medical Record Number: _____________________________ Unit/Bldg: ________________ This is to notify you that the above named patient was returned to the above named facility on _________ at _________ following his/her ❏ ESCAPE ❏ BREACH OF CONDITIONAL RELEASE. (date) (time) Patient returned via: ❏ self ❏ police _____________________ (specify agency) ❏ family ❏ other ______________ (specify) Location of patient when found: _________________________________________________________________ Incident(s) that occurred to patient during elopement ❏ None/unknown ❏ Assault ❏ Suicide attempt ❏ Drug/Alcohol use ❏ Rape ❏ Self-injurious behavior ❏ Suicide ❏ Other Severity of injury/damage to patient ❏ No treatment/injury ❏ Medical intervention required ❏ No property damage ❏ Unknown ❏ Hospitalization required ❏ Minimal property damage ❏ Minor first aide ❏ Death ❏ Substantial property damage Incident(s) committed by patient during elopement ❏ Assault ❏ Homicide ❏ Rape ❏ Theft ❏ Breaking & Entering ❏ None/Unknown ❏ Other Severity of injury/damage to victim (other than patient) ❏ No treatment/injury ❏ Medical intervention required ❏ No property damage ❏ Unknown ❏ Hospitalization required ❏ Minimal property damage ❏ Minor first aide ❏ Death ❏ Substantial property damage Signature and Title of Responsible Professional DISTRIBUTION: Any law enforcement office notified HIM Initial examiner if involuntarily committed Area program (if appropriate) Form No. DMH 5-83-01 Revised September 2001 Risk management coordinator Official placing patient on detainer Next of kin/legally responsible party Clerk of Superior Court in county of commitment NOTICE OF RETURN OF ESCAPEE OR CONDITIONAL RELEASE American LegalNet, Inc. www.USCourtForms.com