Date
01/04/2013
--
S~ter County Detention C--.::1ter
CRIMINAL ARREST DATA
Booking Number
2013-000032
NAME Last First Mi Alias'
URBINA, DAWN MARIE
ADDRESS (Clty,State,Zip Code) Phone No. Race Sex
914 N ROCKINGHAM AV TAVARES FL 32778 (352) 602-9838 W F
D.O.B. AGE P.O.B. HEIGHT WEIGHT HAIR EYES BUILD
02/11/1970 42 NEW JERSEY 5'02" 200 BLU
ARREST NUMBER S.S. NUMBER TIME BOOKED ' TIME PROCESSED
155-60-4239 22:05:00 23:50:00
OCCUPATION EMPLOYER SCARSfTATIOOS
DISABLED SCAR ON LEFT FOOT
NEXT OF KIN & RELATIONSHIP (Mother,Father,Wife,Husband,etc.) PHONE NO. RELIGION \ ,
NIA
MEDICAL PROBELMS/INFECTIOUS DISEASES ATIORNEY (If Known) MARITAL STATUS
Married
ARREST (Date & Time) ARRESTING OFFICER ARRESTING AGENCY BOOKING OFFICER RECEIVING OFFICER
MORROW SGT. RANDALL
TIME OF WEAPONS/DRUGS BOND DATE ADDED & AGENCY
STATUTE # OFFENSE ARREST OR ALCOHOL INVOLVED
01/04/2013
COMMIT OIC 29 Days: Owls - 2nd Off 21:43:3 NONO Sese
OBTS# OFFENSE TYPE CASE/ACTMTY # WARRANT/CAPIAS/CITATION # ARRESTING OFFICER
6001031383 Misdemeanor 2013000831 2011 CT001507 S. Franklin
01/04/2013
322.34(5) Nonmoving Traffic Viol - Drive Whil 21 :43:5 NONO .2000 Sese
OBTS# OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION # ARRESTING OFFICER
6001031383 Felony' 2012-000821 S Franklin
OBTS# OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION # ARRESTING OFFICER
OBTS# OFFENSE TYPE CASE/ACTIVITY # 'WARRANT/CAPIAS/CITATION # ARRESTING OFFICER
OBTS# OFFENSE TYPE CASE/ACTIVITY # WARRANT/CAPIAS/CITATION # ARRESTING OFFICER
Inmate Guide Book # Orientation Conducted: Y TELEPHONE USED: STATUS NURSE NOTIFIED
YES Inmate Signature: Number: o
o
O
Threat / Violent ES Risk SUi Risk Medical Alert Number: PHOTOGRAPH
o O o Number: o
HOLD INFORMATION Right Thumb/Admission Right Thumb/Release
bin # 206
RELEASE INFORMATION
TURERCULIN PPD
RACE/SEX
\') \/S
lNITIALSKlNTEST
DATE GIVEN: -L'.L{ \-->..~---,--,-1-,\3=- _ DATE READ: --1~--"-I......,a"","N",--\-,-,3=- _
SITE GIVEN: -"l..;_~,,--'i\-,-,--- _ SIZE: Cb mm
LOT #: 'A.~ ':0'--\
NURSE:9-" \ h)..N\a~~ ~C\.
I have received a fact sheet on TB and have had the opportunity to have my
questions answered I agreed to TB testing by PPD. I understand the PPD skin test
must be read 72 hours after being administered. I have never had a positive
reaction to a TB skin test, nor have I ever been treated with TB drugs.
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Signature
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Date :
9:, \ '\ \ ,meN ~s £1;.,0, 'In /\3
Witness Signature Date
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SUMTER COUNTY DETENTION CENTER
HEALTH INFORMATION TRANSFER SUM:MARY
CONFIDENTIAL AND PRIVlLEGEI) INFORMATION
FOR PROFESSIONAL USE ONLY
(pLEASE SEAL ill AN ENVELOPE AND MARK CONFIDENTIAL INFQ,RMATION)
DATE ~ -~~-1~3,,---_
SENDING FACILITY SUmter County Detention Center
eo 219 E. Anderson Avenue
CITY I COUNTY Bushnell, FL 33513
TELEPHONE (352) 569-1nO
NAME I 1 &1..\.u.~ I ~ \ 0,,,,,,, INMATE # j 2l- V 03 ";t--
D.O.R ~ -11- f) 'D RACE/SEX-"W<>q.{--l-f"_' _
TRANSFERRING.TO: ~"....~""""'\_L
...•• / _
, (A~CY)
MEDICALIDENTALIPSYCHIATRIC PROBLEMS: _~_--.~lR~' =4=-- _
ALLERGIES: 0!)~\0:: 0 .J
CURRENT MEDICATION: ,YES I/'NO IF YES, COMJ>LETE THE '
FOLLOWING:
DRUGIDOSAGE _
REASON _
TESTEDfTREATED FOR sm
------------------
(TYPE)
LAST PHYSICAL EXAM: J -\1)-1.-2>-.-' __
(DATE)
DATE TREATMENT STARTED _
SPECIALDIET __ YES ~ NO(DEsCRmE) _
HOSPITALIZATION WnHIN PAST YEAR YES v NO
REASON: PHYSICAL PROBLEM MENTAL PROBLEM
IF YES, DATE OF LAST HOSPITALIZATION: _
PSYCHOTROPIC MEDICATION WITHIN PAST YEAR YES "--"' NO
--- oJ
SELF INJURIOUs OR SUCIDAL BERA VIOR WITHIN PAST 'YEAR _ YES -.L::::'NO
IF YES, DATES ~_
CURRENTLY ON SUICIDE WATCHIPRECAUTIONS
---
YES l:7' NO
FORM COMPLETED BY 1...+&~~~~"""'""'),-.q.m""".,Ll"___+A_\_\.!Cw'---- _
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0- (SIGNATURE/TITLE)
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Patieht Name \'kD\l\\(:, ,,Ul0W'\\ :mcMAS E. L;WGk.""7 ME:Drc..u; CENTER
1415 S US Hwy301 .SUD.i:.err:L1.~e, n 33Sas
OOB; a,1\\I]CJ (352) 793-5900 • Fa:x (352) 793-9558
~ COmm:R, DE'mf.rIOR CSNTER
ALLERGIES: . C'aA\pff> /
'. MEDICATION RECORD
MEDICATIONS/STRENGTH I SIG DAn:S .,
~g ga&X& £x xXx I"XXXJ *8 <XJX'
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FORloJEDIo.TION RECORD
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Conti:ms Onc!langee
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n/c Di3con~~u8 ~~a ti.=:.a .lC::.i:L (::!; S::, e~::;
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SUMTEJ' ~t)UNTY MEDICAL DEPT. INMAP- ..~l{EENING FORM
,
NAME: \jS})\ffiS):),,\A\D ID# Q:,~C\C5~ DOB N.)\\/,-c::, DATE \ In /\3
SS# \S':1- kD-lj a"C1 SEX \=" RACE U,) Any known ALLERGIES Ccd~\\~
SPECIAL HEALTH REQUIREMENTS: _~_- ~""_~_.~_' _
BP: \
~l'\.
PPD: \ \ Results: \ I \
PERSONAL PHYSICIAN: YE~ NAME & LOCATION ---- _
PSYCmATRIST~ YEQ IF YES, NAME & LOCATION _
CIRCLE: Y for Yes 01" N for No. EXPLAIN ALL YES ANSWERS RECEIV.ING VISUAL OBSERVATION
*Did the inmate I'equire emel"gency medical treatment pdol" to anival? Y 00 yes, where _
***Has the inmate swallowed, inhaled, injected or ingested any illegal substances within the last 72 hours.
IF YES, WHEN & WHAT: \)0)
------------------------------
1. Has the inmate ever had or currently being tI"eated for:
A. Asthma Y or G. High Blood PI"essure Y OJ"
B. Ulcel"s YOI' H. Mental Health Problems Y 01"
C. Diabetes YOI' I. Any Communicable Diseases YOI'
D, Epilepsy Y 01" J. Any Known Infectious Diseases YOI'
E. SeiZUl"eS Y 01" Hepatitis? HIV? STDs? TB? Other? -----\lHf--
F. Hear"t Condition Y 01" K. Any Other Special Conditions Repol"ted Y 01"
Does the inmate exhibit any 01' complain of the following:
A. Unconsciousness
B. Visible signs of illness
Y 01" ~
Y 01'.
E. Fainting
F. Head Injul"y, yorf
YOI'
C. Injnry YOI' \ . G. Any symptoms I"equidng
D. Bleeding YOI' immediate medical attention YOI'
IF YES, EXPLAIN
-------------------------------------
2. Does the inmate have any of the following observed or reported:
A. Signs of Fevel"
B. Cough
YOI'
Y 01"
J. Jaundice
K. Needle Mal"ks
Y 01' Jt
YOI"~
C. Rash 01" Infection YOI' L. Body Vel"min
~orN
D. Cuts YOI' M. Minol' Injudes YOI'
E. Open Sores Y 01' ,N. Bl'Uising
YOI'
F. Body Defol'mities . YOI' O. Nose Bleeds
YOI'
G. Visual PI"oblems YOI' P, Skin Lesions
YOI"
H. Hear'ing PI"oblems YOI' Q. Lethargy .Y 01'
L Weight Loss Y 01' R. Difficulty Swallowing YOI'
IF' YES, EXPLAIN _
3.; Does i~~ate's behavior or appearan! suggest the risk of: .
A. SUIcide Y or C. Any Abnormal Behavior
B. Assault Y or . Yor~
Does the inmate appear:
A. Alert \l or N C. Cooperative torN
B. Orientated lorN D. Conscious i:\orN
..
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4. Does thdnmate appear to be under the influence of drugs or alcohol?
If yes, what"type of substance is suspected?
5. Does the inmate show any symptoms of withd,'awal?
If Yes, is the,'e:
A. Shakiness Y or N
B. Hallucinations Y or N
6. Do you use Alcohol? Y 01''- 7. Do you use Drugs? Y~
If Yes: ' If Yes:
Method' . Method _
What Kind What Kind _
How Much - " How Much
Hdyv Often How Often ---------
Last Date & Time Used _ ---------
Last Date & Time Used _
8. Is the inmate's mOb,i1ityI"estricted in any way: :\.,
A. Cast , Y orN D. Deformity YOI' '\
B. Crutches, Y orN\ , E. Other ' Y o~
C. Injury Y o~ ,
9. Has the inmate ever taken or currently taking any medication(s) prescribed by a physician? Y or~
'If yes, name of the medication _' _
10. Does the inmate I"eport being hospitalized by a physician or psychiatrist within the last year? YOI' \
If yes, When . Where By what doctor _
II. Has there eVel"been thought of suicide 01" an attempted suicide reported by the inmate? Y or ~
If yes, how long ago? _
12. Does the inmate have a painful dental condition? Y o~ If yes, what? _
** IF the inmate is a FEMALE, does she report to be pregnant? Y or~fyes, how many weeks? _
., Have you recently given birth or had a miscalTiage? Y or ~ yes, explain: _
Whellwas your last Menstrual Period? ,'((\\ !~\\\: "
I have answered all questions truthfully. I have been explained how to obtain
medical services through sick call. I understand that I am responsible for any and all'
medical expenses occurred before, during mid after my incarceration at the Sumter
COUlltyDetention Center. 1also hef'eby give my consent for professional medical
services to be provided to me by the jail.
~\\)~\2~~
WINTNESSED BY
~fkm,~ SIGNED BY INMATE
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R~EWEiBY
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