1. Admission/Discharge Form

• Personal Property Log
• Prescreening Form

2. Basic Rules and Guidelines for Youth Attendants

3. Client Health Checklist

4. Client Illness Report

5. Contract for Youth Attendants

6. Discipline Policy

7. Extraordinary Incident Report

8. Observation Log

9. Operating Procedures for Youth Attendant

10. Shift Summary

Admission/Discharge Form

Reason for placement
_______________________________________________________________
_______________________________________________________________

Date of placement
_______________________________________________________________

Admittance time am/pm
_______________________________________________________________

Client Data

Name (Last, First, Middle)
_______________________________________________________________

Street address
_______________________________________________________________
_______________________________________________________________

City, State Zip
_______________________________________________________________
_______________________________________________________________

Age_______ DOB_______ Race (check one) American Indian Black Asian White

Sex_______ Height_______ Hair _______Weight _______Eyes_______

Ethnicity: Hispanic  Non-Hispanic

Currently wearing
_______________________________________________________________
_______________________________________________________________

Identifying characteristics
_______________________________________________________________
_______________________________________________________________

Currently on probation or under the custody Yes  
of the Division of Juvenile Services or County? No
Case Manager:__________________________________________________

Parent/Guardian Data

Name
_______________________________________________________________
_______________________________________________________________

Street address
_______________________________________________________________
_______________________________________________________________

City, state, zip
_______________________________________________________________
_______________________________________________________________

Home phone___________________  Work phone_______________________

Parental contact by Law Enforcement Officer? Yes No
If yes, comments:
_______________________________________________________________
_______________________________________________________________

JHP parental contact:_____________________________   Date___________
By whom:_________________________________   Time am/pm__________

Outcome/comments:
_______________________________________________________________
_______________________________________________________________

Tentative release plans?
_______________________________________________________________
_______________________________________________________________

Admissions

Admitting JHP Worker (print)_______________________________________
Signature_______________________________________________________

Referring Law Enforcement Officer (print)____________________________
Signature_______________________________________________________

Reason for admission:
_______________________________________________________________
_______________________________________________________________

Admission notes:
_______________________________________________________________
_______________________________________________________________

Describe youth’s attitude, any observations:
_______________________________________________________________
_______________________________________________________________

Approved for visitation/phone calls:
_______________________________________________________________
_______________________________________________________________

Release

Discharge instructions:

1. Release to parent (if appropriate)
2. Release by juvenile court authorization
3. Release by referring law enforcement officer
4. Permission to release to:

Name _________________________________________________________

Relationship ____________________________________________________

Juvenile Court Official/Law Enforcement Agency giving permission
for release (print)
______________________________________________________________

Date/time of authorization ________________________________________

Releasing JHP Worker (print) _____________________________________

Signature______________________________________________________

Date released:________________   Time released:______________ am/pm

Parent/guardian/adult receiving juvenile ____________________________

Signature_____________________________________________________

Personal Property Log

The following items were removed from:

Name: _________________________________   Date of Birth:____________

The confiscated personal belongings are maintained by: (Police or Sheriff’s Department)
_______________________________________________________________
_______________________________________________________________

Items include:
_______________________________________________________________
_______________________________________________________________

I understand that I can pick these items up from the above-named agency between 8 am and 5 pm
from the Property Officer.
Juvenile’s signature:______________________________________________
Those items maintained by the JHP include:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

I understand that these items (barring contraband) will be returned to me upon my release.
Juvenile’s signature:
_______________________________________________________________
_______________________________________________________________

I took possession of the above items that were confiscated by the Juvenile Holdover Program.
Juvenile’s signature:__________________________   Date:______________
JHP Worker’s signature:_______________________  Date:______________

• Is the youth in need of immediate medical attention? Yes  No
  If yes, law enforcement must have these needs addressed prior to JHP admission.

• Is the youth in need of detox? Yes  No
  If yes, the JHP is an inappropriate placement.

• Does the youth agree to follow the rules of the JHP? Yes  No
  If not, youth can be denied entry.

• Has the youth been searched? Yes  No
  Inform them of policy to also search upon entry into the JHP site.

• Have police confiscated any contraband? Yes  No
  Cigarettes will not be returned to the youth.

• Have the juvenile’s personal belongings been secured? Yes  No
  If no, please complete the Confiscation of Personal Belongings section above.

• Admission notes (anything from behavior/attitude to cuts and bruises):
  _______________________________________________________________
  _______________________________________________________________
  

Basic Rules and Guideline for Youth Attendants

• Youth attendants are responsible for the youth while he or she is in the juvenile holdover program.

• The youth attendant’s role is to be there, listen, and supervise.

• Youth attendants must be the same gender as the youth being supervised.

• Youth attendants must stay awake and alert.

• Youth attendants should not be on duty for more than 8 hours.

• Confidentiality issues:
  • Make sure the youth understands that important issues they discuss with you will be shared with the court.
  • Do not tell anyone who the youth is or anything about the youth.

• If you are in a law enforcement center, do not report anything that you may observe there.

• If the youth is a relative or friend and you feel uncomfortable supervising her/him, ask to call another child care provider.

• If a youth tries to leave the room, try to talk with him/her about the consequences of leaving. DO NOT try to bar the door or restrain the youth in any way.

• If a youth becomes violent, has a drug reaction, leaves the room, or some other unusual incident occurs, the child care provider should notify law enforcement immediately.

• Take time to think about the clothing that you are wearing and items that you are taking into the juvenile holdover program. Could these cause potential problems?

• Youth attendants may be asked to dispense medication. Do not give ANY medication without approval of a doctor or nurse.

• Make a few notes on the Observation Log about the youth’s activities and behavior. This helps the court as well as the relieving child care provider.

• Youth attendants are part-time, temporary, county employees. Youth attendants are not eligible for sick leave, vacation time, medical, and other benefits of a full-time employee.

• Each county has its own policies, procedures and guidelines. Please make sure you are familiar with them.

Client Health Checklist
Name ______________________________________________ Date ____________________________
Interviewer ___________________________________________________________________________

• Are you having any health problems at the present time? Yes No
  If yes, what?
  _____________________________________________________
  _____________________________________________________

• Have you had any of the following problems in the past 24 hours?

  Specify comments:

Sore throat  Yes  No
Earache  Yes  No
Swollen glands  Yes  No
Nausea/vomiting  Yes  No
Headache  Yes  No
Skin rash  Yes  No
Fever/chills  Yes  No
Abdominal pain  Yes  No
Kidney/urinary problems  Yes  No

• Do you have any of the following medical problems?

Rheumatic fever  Yes  No
Diabetes  Yes  No
Epilepsy  Yes  No
Hepatitis  Yes  No
Venereal disease  Yes  No
Mononucleosis  Yes  No

• Have you taken an AIDs screening test or do you feel you may have been exposed to AIDs?  Yes  No

• Do you think you have been exposed to any other communicable disease in the past two or three weeks?  Yes  No
  If yes, what?

• Are you allergic to anything, like aspirin, food, medicine, etc.?  Yes  No
  If yes, what?

• Are you taking any kind of medicine or shots?  Yes  No
  If yes, what?
  

  Physician who ordered it:
  ______________________________________________________________
  Do you have it with you?  Yes*  No *
  If yes, Youth Attendant should complete Medication Log Sheet

• Name and, if known, clinic of your family doctor:
  _______________________________________________________________
  _______________________________________________________________
  

• Have medical personnel been consulted?  Yes  No
  If yes, what recommendations were made?
  _______________________________________________________________
  _______________________________________________________________
  

• Have you ever tried to hurt yourself?  Yes  No
  If yes, when and how?
  _______________________________________________________________
  _______________________________________________________________
  

• Have you used controlled substance/alcohol in the past 24 hours?  Yes  No
  If yes, describe substance, amount, method, and time:
  _______________________________________________________________
  _______________________________________________________________
  

• For girls only: Do you take birth control pills?  Yes  No
  If yes, when did you take your last pill?
  Date of last menstrual period:
  _______________________________________________________________
  _______________________________________________________________
  

Client Illness Report

Client Name _________________________________________________________

Date/time of self-report or observation ____________________________________

Symptoms/current condition:

___________________________________________________________________
___________________________________________________________________

When did it start?
___________________________________________________________________

Have you had this problem before?  Yes  No
If yes, when? What did you do for it?
___________________________________________________________________
___________________________________________________________________

Do you think you may have a fever?  Yes  No
If yes, obtain reading.
Result______________________________________________________________

Ask-A-Nurse recommendations (if applicable)
Date/time of call:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Other comments/plans employed:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Contract for Youth Attendants

This agreement by and between __________________________ County and ______________________ asserts the following understandings and agreements:

The County of _______________________________ and the __________________________________ have entered into agreement for the use of Juvenile Detention Services subsidy funds. The purpose of the program is to provide funds to counties to establish alternatives to jail for juvenile delinquent offenders who have been arrested and who are awaiting a hearing and/or placement. Funding for this program has come from _____________________________________________________ and Juvenile Justice Delinquency Prevention Act funds.

The County hereby retains _______________________________ to provide services as a Youth Attendant The services to be provided will be consistent with the individual component description and the policies and procedures attached hereto, and incorporated into this contract by reference.

The Youth Attendants fully understands and expressly agrees that he/she is not an employee of the County nor the State of ________________________ and that no income tax or social security will be withheld from payments. The Child Care Provider also understands that he/she has no rights to unemployment or workers’ compensation as a contracted individual.

The Youth Attendant is not responsible for being available at any given time unless agreed upon, nor shall the County be responsible for providing work for the Youth Attendant.

The County shall, following submission of the appropriate forms and documentation, make payment to the Youth Attendant at the rate designated for each individual detention subsidy program component. After payment has been made to the Youth Attendant, the County will forward documentation to the ____________________________________________________ for reimbursement.

This contract can be terminated without cause upon 14 days prior written notice by either party.

The terms and conditions of this contract are accepted and approved by the County and _____________________________________________ as evidenced by the signatures below.

Juvenile Holdover Youth Attendant___________________________________

Juvenile Holdover Program Coordinator_______________________________

County ___________________________________   Date_________________

Discipline Policy

It is the policy of the _____________________ Juvenile Holdover Program that the youth attendant shall NOT use physical force to restrain a juvenile from leaving the facility but should attempt to have the juvenile remain through the use of various communication skills.

In addition, youth attendants are prohibited from using any disciplinary acts that would cause physical or emotional harm to juveniles.

Prohibited forms of restraint or punishment include:

• Corporal punishment: hitting, beating, shaking.

• Verbal abuse: cursing, threats, derogatory remarks about the juvenile or the juvenile’s family.

• Binding or tying to restrict movement.

• Enclosing in a confined space, such as a closet, locked room, box or similar cubicle.

• Denying meals, clothing, and showers.

I have read and understand this policy.
Juvenile Holdover Youth Attendant ________________________________________
Date_______________
*NOTE: For use in nonsecure or staff secure program only.

Extraordinary Incident Report

Name ______________________________________  Date __________________

Interviewer _________________________________________________________

Your Account of Incident:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Observation Log

Youth’s name:
___________________________________________________________________

Log No. of
___________________________________________________________________

The purpose of this log is to record behaviors and observations and should provide information regarding a youth while in the Juvenile Holdover Program. Entries are to be made every hour following admission.

Hour #1    Time:____________ Attendant Initials:_________
Observations:
___________________________________________________________________
___________________________________________________________________
Comments:
___________________________________________________________________
___________________________________________________________________

Hour #2   Time:____________ Attendant Initials:_________
Observations:
___________________________________________________________________
___________________________________________________________________
Comments:
___________________________________________________________________
___________________________________________________________________

Hour #3   Time:____________ Attendant Initials:_________
Observations:
___________________________________________________________________
___________________________________________________________________
Comments:
___________________________________________________________________
___________________________________________________________________

Hour #4   Time:____________ Attendant Initials:_________
Observations:
___________________________________________________________________
___________________________________________________________________
Comments:
___________________________________________________________________
___________________________________________________________________

Hour #5   Time:____________ Attendant Initials:_________
Observations:
___________________________________________________________________
___________________________________________________________________
Comments:
___________________________________________________________________
___________________________________________________________________

Operating Procedures for Youth Attendants

• The youth attendant must address the following issues when a youth enters the holdover program:
  • Has the youth been searched? If not, ask law enforcement to do so.
  • Have the youth’s parents and/or guardian been notified? If not, attendant should notify the parents and/or guardian.
  • Does the youth have any medical problems requiring medication/ treatment? Emergency medical treatment must be done before the youth enters the juvenile holdover program. Youth attendants are not to dispense medication, not even aspirin.
  • Why is the youth being detained in the holdover program?
  • The child care provider should know why the youth is being held in order to anticipate problems.
  • What is the youth’s emotional status and attitude?
  • The child care provider should try to determine how the youth is feeling and behaving in order to anticipate problems.
  • Is the youth allowed to have visitors/telephone calls?
  • Determine who is allowed to visit/call. All items brought to the youth by visitors must be searched.
  • Have the youth’s personal effects been safely secured?
  • If the youth surrenders money and/or personal property to you, a record of each of these properties shall be signed by both the juvenile and the child care provider. Each refusal to sign should be documented.
  • When did the youth eat last?
  • Determine what arrangements will be made for food to be provided.
  • Fill out the Admission Form and the Health History Checklist as thoroughly as possible.
  • Review the rules and regulations of the juvenile holdover program with the youth and have him/her sign the statement that they have done so.
  • Keep the youth attendant Observation Log on the youth’s activities while in the JHP to give to the relieving youth attendant or to appropriate court personnel.

 

• Relieving child care providers must read the log and make additional entries.

• The last child care provider will release the youth from the holdover program, have the person sign for the youth, noting the date and time on the admission/discharge form.

Shift Summary

Client’s name:
________________________________________________________

Shift filled:
________________________________________________________

Date/time ________________________________________________
to _______________________________________________________

Worker completing summary:
________________________________________________________
________________________________________________________

Overall behavior:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Issues or concerns client has shared or had questions about:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

My concerns and things to watch:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Special instructions:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

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