ch day by the medical provider. Comments: i.e., Conduct. Attitude, etc. Additional comments on reverse side must include date, signature, and title. OIC Signature: CNC must sign all record sheets each shift. (OIC - Unit Officer) PDF Prescribed by P5270 This form replaces BP-292(52) dated AUG 2011. EFTA00056

ch day by the medical provider. Comments: i.e., Conduct. Attitude, etc. Additional comments on reverse side must include date, signature, and title. OIC Signature: GIG must sign all record sheets each shift. (OIC - Unit Officer) PDF Prescribed by P5270 This form replaces BP-292(52) dated AUG 2011. EFTA00056

each day by the medical provider. Comments: I.e.. Conduct Attitude, etc. Additional cowmen% on reverse side must include date. signature, and title. OIC Signature: OIC mist sign all record shoots each shift. (Ole - Unit Officer) PDF Prescabed by P5270 This form replaces BP-292(52) dated AUG 2011. SDNY_00013

each day by the medical provider. Comments: ie.. Conduct. Attitude. etc. Additional comments on reverse side must Include date. signa we, and title. OIC Signature: CIC must sign all record sheets each shift. (OIC - Unit Officer) POF Presalbed by P5270 This form replaces BP-292(52) dated AUG 2011. EFTA000549

--- - - · -- --- - - - - · --- - - - --- - - --- 07-20-2019 Day y . - -- - - - --~ - - - -- - o7-w -201s Eve V N No - - - - - - - - - -- - - -- OIC Signature EXPLANATORYNOTES:Pertinent Info: l.e., Epilepllc; Diabetic; Suicidal; Assaultive; etc. Meals/SH: Shower - Yes (Y); No (N); Refused (R)Out-of-Ce0 Ti