CIT DATA COLLECTION FORM

AGENCY Case Number:
/ DCJ Case Number:
/ Date DCJ Form Received:
(mm-dd-yyyy)
Date of Call: (mm-dd-yyyy)
/ Time of Call:
AM PM / Total Time Spent on Call:
(in minutes)
Incident Location:
Street Address/Intersection: / City: / Zip:
Original Complaint:

Responding Officer Information

First Name: / Last Name: / Badge #: / Assignment:
Law Enforcement Agency: (Circle one)
Adams Region
6. Westminster
12. Aurora
28. Broomfield
29. Adams SO
30. Northglenn
31. Commerce
City
32. Thornton /
Arap/Doug/Elbert
2. Englewood
9. Arapahoe SO
10. Douglas SO
11. Cherry Hills
13. Littleton
14. Greenwood
Village
24. Glendale
34. Parker
35. Elbert SO
44. Lone Tree
46. Sheridan
47. Castle Rock /
Boulder Region
48. Boulder SO
49. Longmont
50. Nederland
51. Lafayette
52. Louisville
53. Boulder
54. Erie
55. CU-Boulder
Denver
8. Denver /
Jefferson Region1. Arvada
3. Golden
4. Jefferson SO
5. Lakewood
7. Wheat Ridge /
Larimer Region
16. Larimer SO
18. Loveland
20. Berthoud
22. Ft. Collins
27. CSU 45. Johnstown
Pueblo Region
38. Pueblo
39. Pueblo SO /
Weld Region
15. Weld SO
17. Greeley
19. Ft. Lupton
21. Ault
23. Lochbuie
25. Evans
26. Firestone
43. Miliken
45. Johnstown

Consumer Information

First Name: / Last Name: / Date of Birth:(mm-dd-yyyy)
Gender: / 1. Male
2. Female / Ethnicity: / 1. Caucasian
2. African American / 3. Hispanic
4. Native American / 5. Asian
6. Other
Address:
Street Address/Intersection: / City: / Zip: / Phone Number:

Mental Health

Does officer believe mental illness was a factor in the call?
0. No 1.Yes 2. Cannot Determine / Does officer believe the individual was influenced by alcohol and/or drugs at time of the call? 0. No 1.Yes 2. Cannot Determine
Does an individual/family member/other describe the consumer as having a mental illness? / 0. No
1. Yes
2. Don’t Know /
If yes, what type of illness(s)?
Is the individual currently in treatment? / 0. No
1. Yes
2. Don’t Know /
If yes, where?
Is the individual
currently prescribed medication?
/ 0. No
1. Yes
2. Don’t Know
/
If yes, what type of medication(s)?
/
If yes, are they taking meds as prescribed?
/ 0. No
1. Yes
2. Don’t Know
Insurance: Note: Private insurance carriers sometimes require the use of specific hospitals. IF POSSIBLE, use this information to route the consumer to the appropriate hospital.
0. None
1. Medicaid / 2. Medicare
3. Private / 4. Don’t Know
5. Medicaid and Private
Was the SWAT or Negotiation Team called? / 0. No
1. Yes / If no, would the SWAT or Negotiation Team have been utilized prior to CIT? / 0. No
1. Yes
Threat Assessment: / 0. No Threat / 1. Suicide Threat
2. Suicide Attempt / 3. Threat to Harm Other(s)
4. Threat to Harm Police
Weapons Present or Method of Suicide Attempt/threat to harm:
0. None
1. Firearm / 2. Edged Weapon
3. Hanging / 4. Jumper
5. Traffic / 6. Overdose
7. Police / 8. Other (specify)
Injuries: / 0. No
1. Yes / If Yes, Injuries Prior to Police Contact? / If Yes, Injuries After/During Police Contact?
1. Consumer 2. Other(s) / 1. Consumer 2. Other(s)

Was force used?

/ 0. No
1. Yes / If yes, what levels of force were used?

Disposition

Consumer Went to: (Circle one)
0. No facility placement
needed
7. Detox
Mental Health Center
18. Arap/Douglas MHN
19. Aurora MHC
37. Boulder County MH
38. Comm Reach MHC
8. JCMH
48. Larimer Center for MH
39. MHCD
45. Spanish Peaks MHC / Hospital 28. Aurora South Medical
Center
35. Avista
49. Boulder Community
50. Centennial
51. Centennial Peaks
12. Children’s
3. DHMC
26. Estes Park Medical Center
36. Good Samaritan
23. Health One
15. Littleton
52. Longmont United
2. Lutheran
25. McKee Medical Center
21. Medical Center of Aurora
27. North Colorado Medical
Center
33. North Suburban /
40. Parker Adventist
41. Parkview Medical Center
32. Platte Valley
5. Porter
24. Poudre Valley
30. Presbyterian St Luke’s
29. Rose
1. St. Anthony’s Central
34. St. Anthony’s North
13. St. Joe’s
42. St. Mary Corwin
17. Sky Ridge
16. Swedish
4. University
31. VA
6. Other Hospital
(Specify) / Other:
44. Assisted Living Program
(Specify)
9. Jail
14. JAC
20. No contact/Unable to
locate
46. Other Criminal Justice
Involvement (summons, PO)
(Specify)
43. Shelter
(Specify)
10. Other
(Specify)

Consumer Arrested?

/ 0. Not arrested / 1. Felony / 2. Misdemeanor / 3. Ordinance

Prior to CIT, would the person have been jailed, summoned, or ticketed?

/ 0. No / 1. Yes
Officer Time Spent at the Facility:
(in minutes) / Was Mental Health Hold placed?
0. No 1. Yes

Transport

Consumer Transported by: / 1. Police
2. Ambulance
3. Other / If ambulance used, how much time was spent waiting for the ambulance (in minutes)? / Transport: / 1. Voluntary (Cooperative)
2. Involuntary (Uncooperative)

Additional Comments (If you need more room to write, please attach additional sheet(s) of paper)

Office of Research and Statistics, Colorado Division of Criminal Justice Revised 3/22/2006
700 Kipling Street, Suite 1000Phone: 303-239-4455

Denver, CO 80215Fax: 303-239-4491