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Whiting Forensic Hospital Documents

In June 2024, the Mental Health Justice Clinic filed a Freedom of Information (FOI) request with the Connecticut Department of Mental Health and Addiction Services (DMHAS) on behalf of Keep the Promise Coalition. Keep the Promise is Connecticut’s only grassroots social justice coalition led by and for people with lived experience of distress, crisis, and psychiatric oppression. They use this experience to advocate for systems change and expand human rights protections against force, coercion, and other oppression in Connecticut’s mental health system.

Whiting Forensic Hospital (WFH) is a state-run psychiatric facility in Middletown, Connecticut. Individuals are committed to WFH for restoration of competency to stand trial, upon being found not guilty by reason of their mental health condition, during or upon completion of a prison sentence, or through civil commitment proceedings. WFH is Connecticut’s sole maximum security psychiatric facility.

The goal of MHJC’s June 2024 FOI request was to obtain documents related to the operating procedures of Whiting Forensic Hospital, which DMHAS does not currently (as of May 2025) publish publicly. Specifically, we sought policies that would assist the public access to policy documents and further public engagement with institutional oversight over topics such as physical restraint of patients, incident management, and professional visits.   

In total, DMHAS turned over 280 documents. These documents are organized in the following categories. Use the links below to access the full set of documents or individual categories.

Operational Procedure Manual (OPM)

This section contains all operating procedures for Whiting Forensic Hospital as of March 21, 2025, organized by chapter. Select a chapter to view and download policies within that chapter.

Download Chapter 1: Ethics, Rights, and Responsibilities (PDF)

 

This chapter contains the following policies:

  • Procedure 1.1 Ethics, Rights and Responsibilities

  • Procedure 1.2 Operationalizing the Code of Ethics

  • Procedure 1.3 (Reserved for future procedure)

  • Procedure 1.4 Informed Consent

  • Procedure 1.5 Patient’s Request for Treatment by Prayer Alone

  • Procedure 1.6 Advance Health Care Directives

  • Procedure 1.8 Do Not Resuscitate (DNR) Order and Bracelet Protocol rev. 2/26/20

  • Procedure 1.9 Patient Complaints and Grievances effective 10/26/23

  • Procedure 1.10 Visitation effective 6/6/24 RI 01.07.05

  • Procedure 1.11 Patient Searches (rev 12/5/19, 11/19/20)

  • Procedure 1.12 Access to Advocates for Recovery/Treatment Planning

  • Procedure 1.13 (Reserved for future procedure)

  • Procedure 1.14 Organ/Tissue Donation

  • Procedure 1.15 Arrest of Patients at Whiting Forensic Hospital

  • Procedure 1.16 Privileged Conversation for Patients on Continuous or More Restrictive Levels of Observation Status

  • Procedure 1.17 Conservatorship

  • Procedure 1.18 Patient Communication and Restriction of Communication

  • Procedure 1.19 Patient-to-Patient Sexual Harassment

  • Procedure 1.20 Recording and Filming of Patients

  • Procedure 1.21 Videotaping of Public Hearings Held on WFH or CVH Campus

  • Procedure 1.22 Registration of Sexual Offenders

Download Chapter 2: Provision of Care, Treatment, and Services (PC), Assessment Continuum of Care (PDF)

 

This chapter contains the following policies:

  • Procedure 2.1 Fall Risk Screening, Assessment and Management effective 6-30-23

  • Procedure 2.2 Use of Restraint Chair New 12/2/19

  • Procedure 2.3 Sexual Assault

  • Procedure 2.4 Evaluating Comprehension of Patient Education

  • Procedure 2.5 Assessment and Management of Pain effective 4/17/24

  • Procedure 2.6 Integrated Treatment Planning Process rev. 2/8/21

  • Procedure 2.7 Discharge Planning

  • Procedure 2.8 Evaluating and Managing Suicide Risk Effective 10/26/23

  • Procedure 2.9 Linguistic Support: Use of Interpretation and Translation Services Effective 9/19/23

  • Procedure 2.10 Elopement/Escape and Unauthorized Absence

  • Procedure 2.11 Special Observation Effective 3/18/24

  • Procedure 2.12 Patient Care and Gender Specific Assignment

  • Procedure 2.13 Outpatient and Emergency Visits to Acute Care Hospitals, Staff Expectations and Responsibilities rev. 2/26/20

  • Procedure 2.14 Transfers Among and Between Whiting and Dutcher Services effective 8/25/23

  • Procedure 2.15 Group and Individual Treatment Programs

  • Procedure 2.16 Documentation of Patient Progress and Care

  • Procedure 2.17 Dutcher Service Patient Privilege Levels Effective date 10/10/22

  • Procedure 2.18 Animal Assisted Therapy / Animal-Assisted Activity / Service Animals effective 5/31/23

  • Procedure 2.19 Electroconvulsive Therapy (ECT)

  • Procedure 2.20 Drug and Alcohol Screenings effective 7/10/24

  • Procedure 2.21 Guidelines for Positive Behavioral Support Planning and Implementation

  • Procedure 2.22 Hand-Off Communication Among Caregivers

  • Procedure 2.23 Clinical Consultation

  • Procedure 2.24 Clinical Emergency All Available Code for Psychiatric Emergencies

  • Procedure 2.25 Medication Reconciliation effective 1/30/23

  • Procedure 2.26 Seclusion Use

  • Procedure 2.27 Restraint Use for the Management of Violent or Self- Destructive Behavior

  • Procedure 2.28 Critical Clinical Alarm Systems effective 12/30/22

  • Procedure 2.29 Palliative Care Program

  • Procedure 2.30 Prevention of Tubing Misconnections

  • Procedure 2.31 Hunger Strike new 3/8/21

  • Procedure 2.32 Referral and Admission of Patients rev. 4/27/22

  • Procedure 2.33 Adult CPR with AED Guidelines effective 8/14/23

  • Procedure 2.34 Patient Death: Staff Responsibilities rev. 2/26/20

  • Procedure 2.35 Patient Identification effective 1/30/23

  • Procedure 2.36 Assessment and Management of Non-Suicidal Self-Injurious Behavior (effective 12/2/22)

  • Procedure 2.37 Daily Living Activities–20 (DLA-20) Assessment Process 3/10/21 (effective 4/1/21)

  • Procedure 2.38 Community Integration and Discharge

  • Procedure 2.39 Homework Assignment/Generalization Process rev. 2/8/21

  • Procedure 2.40 Use of Oxygen rev. 2/26/20

  • Procedure 2.41 Mitigation of Risk in Use of Medical Equipment new 1/31/22

  • Procedure 2.42 Responding to a Choking Episode/Swallowing Episode rev. 2/26/20

  • Procedure 2.43 Speech and Language/Communication Services rev. 9/2/21

  • Procedure 2.44 Emergency Medical Response Effective 1/5/23

  • Procedure 2.45 Use of the Humane Isolation Bed/Rolling Bed

  • Procedure 2.46 Guidelines for Weighted Modalities

  • Procedure 2.47 PAP Ventilation (APAP, BiPAP, CPAP) rev. 2/26/20

  • Procedure 2.48 Use of Hospital Cell Phones new 4/11/22

  • Procedure 2.49 Critical Test Results rev. 2/26/20

  • Procedure 2.50 Anticoagulation Therapy and Monitoring

  • Procedure 2.51 CLIA Waive Testing effective 12-19-22

  • Procedure 2.52 Psychiatrist, Physician & APRN Orders

  • Procedure 2.53 Transgender and Non-Binary Care effective 8/4/23

  • Procedure 2.54 Referrals to Physical, Speech Language Pathology and Occupational Therapy effective 6/2/23

  • Procedure 3.1 Dutcher Off-Grounds Supervision of Patients

  • Procedure 3.2 Dutcher Off-Grounds Treatment Activities

  • Procedure 3.3 Dutcher Patient On Grounds Pass Times and Evening Curfew rev. 3/17/21

Download Chapter 3: Medication Management (MM) - PDF

 

This chapter contains the following policies:

  • Procedure 3.1 Emergency and Involuntary Medication

  • Procedure 3.2 Drug-Use Evaluation and Medication-Use Evaluation

  • Procedure 3.3 Medication Event Reporting System effective 11/3/23

  • Procedure 3.4 (Reserved for future procedure)

  • Procedure 3.5 Patient Self-Administration of Medication

  • Procedure 3.6 Patient COVID-19 Vaccination Administration new 2/19/21

  • Procedure 3.7 COVID-19 Vaccine new 2/19/21

  • Procedure 3.8 Medication Renewals new 6-15-22

Download Chapter 4: Infection Management (PDF)

 

This chapter contains the following policies:

  • Procedure 4.1 Surveillance, Prevention and Control of Infections

Download Chapter 5: Improving Organization Performance (PDF)

 

This chapter contains the following policies:

  • Procedure 5.1 (Reserved for future procedure)

  • Procedure 5.2 (Reserved for future procedure)

  • Procedure 5.3 (Reserved for future procedure)

  • Procedure 5.4 Transportation and Assessment of Risk effective 4/5/24

  • Procedure 5.5 Patient and Staff Safety in the Community

  • Procedure 5.6 Risk Management

  • Procedure 5.7 Management of Patient Allegations 7/22/22

  • Procedure 5.8 Patient Safety Event and Incident Management effective 3/1/24

  • Procedure 5.9 Assessment and Reporting of Victims of Abuse, Neglect or Exploitation

Download Chapter 6: Leadership (PDF)

 

This chapter contains the following policies:

  • Procedure 6.1 Please See: Governing Body By-Laws on T-Drive

  • Procedure 6.2 (Reserved for future procedure)

  • Procedure 6.3 Development Revision of Operational Procedures

  • Procedure 6.4 Management of Critical Staffing Levels effective 1/9/23

Download Chapter 7: Management of the Environment of Care

 

This chapter contains the following policies:

  • Procedure 7 Management of the Environment of Care effective 9-26-23

  • Procedure 7.1 Fire-Safety-Management-Plan rev. 7-19-22

  • Procedure 7.1a Fire Watch rev 7-19-22

  • Procedure 7.1b Fire and Smoke Barrier Penetrations rev. 7-19-22

  • Procedure 7.1c Fire and Evacuation Response rev. 7-19-22

  • Procedure 7.2 Environmental Services

  • Procedure 7.3 (Reserved for future procedure)

  • Procedure 7.4 Requesting Use of State Pool Vehicles

  • Procedure 7.5 Safety Hazards

  • Procedure 7.6 Management of Patient Property effective 3/4/24

  • Procedure 7.7 Firearms and Dangerous Weapons

  • Procedure 7.8 Bomb Threats

  • Procedure 7.9 Employee Fit Testing

  • Procedure 7.10 Traffic Control and Designated Parking

  • Procedure 7.11 Interim Life Safety Measures rev. 7-19-22

  • Procedure 7.12 Use of Extension Cords and Surge Protectors

  • Procedure 7.13 Social Environment

  • Procedure 7.14 Space Planning

  • Procedure 7.15 Allowable Patient Personal Property – Electronic Items 8/22/24

  • Procedure 7.16 Security Alert: Active Shooter

  • Procedure 7.17 Hot Spot Environmental Rounds rev. 5/20/22

  • Procedure 7.18 (Reserved for future procedure)

  • Procedure 7.19 Portable Heaters

  • Procedure 7.20 Activity/Welfare Fund

  • Procedure 7.21 Dietary Services

  • Procedure 7.22 Signs

  • Procedure 7.23 Patient Clothing and Linen Request

  • Procedure 7.24 Whiting Safety Management rev 7-19-22

  • Procedure 7.25 Hazardous Material and Waste Management Plan effective 12-19-22

  • Procedure 7.26 Hazardous Materials & Waste, Spill & Exposure effective 5-1-23

  • Procedure 7.27 Panic and Body Alarms Security Systems new 7-1-22

  • Procedure 7.28 Medical Equipment Failure Emergency Response effective 7-20-23

  • Procedure 7.29 1135 Waiver Policy effective 7-20-23

  • Procedure 7.34 Pressure Sensitive Door Alarms effective 12/28/22

Download Chapter 8: Management of Human Resources (PDF)

 

This chapter includes the following policies:

  • Procedure 8.1 Benefits

  • Procedure 8.2 Education Required

  • Procedure 8.3 Education Data Base – Learning Management System (LMS)

  • Procedure 8.4 (Reserved for future procedure)

  • Procedure 8.5 (Reserved for future procedure)

  • Procedure 8.6 (Reserved for future procedure)

  • Procedure 8.7 Employee Attendance Review

  • Procedure 8.8 Employee Organizations

  • Procedure 8.9 (Reserved for future procedure)

  • Procedure 8.10 Employee Assistance Program (EAP)

  • Procedure 8.11 Fair Employment Practices

  • Procedure 8.12 (Reserved for future procedure)

  • Procedure 8.13 Dual Employment Request

  • Procedure 8.14 Hospital Authorized Personnel Identification

  • Procedure 8.15 Leave of Absence

  • Procedure 8.16 Licensure/Certification

  • Procedure 8.17 Agency Compliance Code of Conduct

  • Procedure 8.18 Organization Charts and Staffing Analysis

  • Procedure 8.19 Orientation

  • Procedure 8.20 Authorizations of Overtime Assignments

  • Procedure 8.21 (Reserved for future procedure)

  • Procedure 8.22 Performance Management System

  • Procedure 8.23 Political Activity

  • Procedure 8.24 Position Classifications/Reclassifications

  • Procedure 8.25 (Reserved for future procedure)

  • Procedure 8.26 (Reserved for future procedure)

  • Procedure 8.27 Reporting Alleged Violations of Policies, Procedures, Regulations or Work Rules

  • Procedure 8.28 Employment Separation

  • Procedure 8.29 Staff Request Not to Participate in an Aspect of Patient Care

  • Procedure 8.30 Emergency Housing for Weather Emergencies

  • Procedure 8.31 (Reserved for future procedure)

  • Procedure 8.32 (Reserved for future procedure)

  • Procedure 8.33 Employee Personnel Records

  • Procedure 8.34 Investigation of Alleged Violations of DMHAS Policies, Procedures, Regulations, or Work Rules

  • Procedure 8.35 Workers’ Compensation

  • Procedure 8.36 Pre-Employment Physical Examinations

  • Procedure 8.37 (Reserved for future procedure)

  • Procedure 8.38 Tuition Reimbursement

  • Procedure 8.39 Staff Suggestions

  • Procedure 8.40 Release/Disclosure of Information from Employee Personnel and Employee Medical Files

  • Procedure 8.41 Publishing Related Activities

  • Procedure 8.42 Guidelines Concerning the Prohibition on Sexual or Otherwise Exploitative Relationships Between Employees and Patients/Clients (DMHAS Work Rule #18)

  • Procedure 8.43 Guidelines for Appropriate Dress for All Employees and Visitors

  • Procedure 8.44 Electronic and Voicemail

  • Procedure 8.45 Early Closing and Late Opening – Extreme Weather Conditions

  • Procedure 8.46 Private Forensic Consultation

  • Procedure 8.47 Media Relations

  • Procedure 8.48 Initial Working Test Period

  • Procedure 8.49 Uniform Policy Regarding Activities While on Duty

  • Procedure 8.50 Change in Employee Status

  • Procedure 8.51 Prevention and Management of Patient Violence Directed at Staff effective 3/5/24

  • Procedure 8.52 Description and Orientation of Non-DMHAS Personnel

  • Procedure 8.53 Prevention of Fraud, Waste and Abuse

  • Procedure 8.54 (Reserved for future procedure)

  • Procedure 8.55 Supervision

  • Procedure 8.56 Violence in the Workplace Prevention – Also See Commissioner’s Policy 2.23

Chapter 9: Management of Information (IM) and HIPPA Procedures 

This chapter is split into two sections:

Download Chapter 9: Management of Information (IM) (PDF)

This section contains the following policies:

  • Procedure 9.1 Authorization to Document in the Medical Record

  • Procedure 9.2 (Reserved for future procedure)

  • Procedure 9.3 Faxing Patient Health Information

  • Procedure 9.4 Subpoena of Medical Records

  • Procedure 9.5 Legal Status: Admission and Changes in Legal Status and Probate Court Proceedings

  • Procedure 9.6 Diagnosis- Admission, Discharge and Changes in Diagnosis; Coding of Behavioral Diagnoses using ICD- 10-CM and DSM 5 Criteria; Coding of Medical Diagnoses Using ICD-10-CM

  • Procedure 9.7 Standards for Medical Record Completion

  • Procedure 9.8 Records Retention Schedules for State Agencies effective 4/22/24

  • Procedure 9.9 (Reserved for future procedure)

  • Procedure 9.10 (Reserved for future procedure)

  • Procedure 9.11 Service of Process and Procedure for Acceptance of Notice of Legal Action or Proceedings

  • Procedure 9.12 Internet, Computer, E-Mail, and Phone Use

  • Procedure 9.13 Hospital Census – Reporting Patient Movement

 

Download HIPPA Procedures (PDF)

This section contains the following policies:

  • Procedure 9.14 Provision of Notice of Privacy Practices for Protected Health Information

  • Procedure 9.15 Access to Protected Health Information

  • Procedure 9.16 Amendment of Protected Health Information

  • Procedure 9.17 Accounting of Disclosure of Protected Health Information

  • Procedure 9.18 Request for Confidential Communication of Protected Health Information

  • Procedure 9.19 Authorization for Use and Disclosure of Protected Health Information

  • Procedure 9.20 Resolving Conflicting Authorizations

  • Procedure 9.21 Verification Requirements for the Use and Disclosure

  • Procedure 9.22 Restrictions on the Use and Disclosure of Protected Health Information

  • Procedure 9.23 Use and Disclosure of Protected Health Information Without Patient/Conservator Authorization

  • Procedure 9.24 Use and Disclosure of Protected Health Information, Minimum Necessary

  • Procedure 9.25 Disclosures to Personal Representatives

  • Procedure 9.26 Use and Disclosure of Protected Health Information for Research

  • Procedure 9.27 De-Identification of Protected Health Information

  • Procedure 9.28 Limited Data Set

  • Procedure 9.29 Transporting Medical Records and Documents Containing Patient Protected Health Information 

  • Procedure 9.30 (Reserved for future procedure)

  • Procedure 9.31 (Reserved for future procedure)

  • Procedure 9.32 (Reserved for future procedure)

  • Procedure 9.33 (Reserved for future procedure)

  • Procedure 9.34 (Reserved for future procedure)

  • Procedure 9.35 Confidentiality of Patient Information Access to Patient Information by (Other) DMHAS Facilities

  • Procedure 9.36 Confidentiality of Patient Information – Patient Requests to Examine Records – Inpatient Status

  • Procedure 9.37 (reserved for future procedure)

  • Procedure 9.38 Confidentiality of Patient Information / Processing of Requests for Patient Information

  • Procedures 9.39-9.43 (Reserved for future procedures)

  • Procedure 9.44 Electronic Monitoring/Surveillance System

Download Chapter 10: Fiscal (PDF)

 

This chapter contains the following sections:

  • Procedure 10.1 Purchasing Card Cardholder Work Rules

Download Chapter 11: Nursing (PDF)

 

This chapter contains the following policies:

  • Procedure 11 Nursing Services

Chapter 12: Clinical Disciplines

This chapter is divided into three sections:

 

Download Chapter 12a - Social Work Manual (PDF)

 

Download Chapter 12b - Psychology Manual (PDF)

  • Procedure 12.b.1 (Reserved for future procedure)

  • Procedure 12.b.2 Organizational Structure, Orientation, and Supervision

  • Procedure 12.b.3 (Reserved for future procedure)

  • Procedure 12.b.4 (Reserved for future procedure)

  • Procedure 12.b.5 Psychological Evaluation, Referral and Administration

  • Procedure 12.b.6 Individual Psychotherapy

  • Procedure 12.b.7 (Reserved for future procedure)

  • Procedure 12.b.8 Psychology Services

  • Psychology Appendices

 

Download Chapter 12c - Rehabilitation Therapy Manual (PDF)

  • Procedure 12.c.1 Rehabilitation Therapy Services

  • Procedure 12.c.2 Library Services

  • Procedure 12.c.3 Volunteer Services

  • Procedure 12.c.4 Vocational Rehabilitation Services

  • Procedure 12.c.5 Occupational Therapy Services

  • Procedure 12.c.6 Special Education Services

  • Procedure 12.c.7 Chaplaincy Services

  • Procedure 12c.8 Water Related Activities effective 5/31/23

  • Procedure 12.c.9 Criteria for Referral for Evaluation and Services

  • Procedure 12.c.10 Assessment and Planning of Vocational Rehabilitation

Download Chapter 13: Competency and Restoration (PDF)

 

This chapter contains the following policies:

  • Procedure 13.1 Role of Competency Monitors

  • Procedure 13.2 Acquittee Call-Ins During Temporary Leaves effective 10-7-24

Additional Documents

Policies related to investigations at Whiting Forensic Hospital by DMHAS’s internal police force.

Download Files (PDF)

This section contains the following items:

  • DMHAS Electronic Monitoring Surveillance Systems 2019 policy
  • DMHAS Police General Order 4.02 - Consent to Search and Examine Evidence
  • DMHAS Police General Order 4.02 - Crime Scene Log
  • DMHAS Police General Order 4.02 - Notice of Rights
  • DMHAS Police General Order 4.02 - Voluntary Interview Form effective date 9-01-2023
  • DMHAS Police General Order 4.02 - Management of Investigations
  • DMHAS Police General Order 4.02 - Property and Evidence Control
  • DMHAS Police General Order 4.02 - Response to Unusual Circumstances

Appendices/forms/trainings referenced in the Whiting Forensic Hospital Operational Procedural Manual.

Download Files (PDF)

This section contains the following items:

  • Collaborative Safety Strategies Terms and Definitions rev. 8-1-2023
  • DMHAS RSAT Restraint and Seclusion Application Training FY24-25 rev. 8-2023 (PDF)
  • DMHAS RSAT Restraint and Seclusion Application Training FY24-25 rev. 8-2023 (pptx)
  • DMHAS Video Slide 19 of RSAT Restraint and Seclusion Application Training FY24-25
  • DMHAS-601 Critical Incident Submission Form rev. 92023
  • DPH AE Reporting Categories rev. 11-22-2016 eff 01-2017
  • DPH Connecticut Adverse Event Reporting Categories Effective 2017 - 12-13-2016
  • FDA 3500A MedWatch Instructional Supplement 12-11-2023
  • FDA 3500A_medwatch_Sec_08-02-2024
  • WFH Incident Reporting at Whiting Forensic Hospital - no date
  • WFH-469 Personal Safety Preferences Form Eng
  • WFH-469 Personal Safety Preferences Form Spa
  • WFH-480A Restraint-Seclusion eff 11-20-2023
  • WFH-480B Restraint-Seclusion Observation Monitoring rev. 2-19
  • WFH-480C Restraint-Seclusion Reorder eff 11-20-2023
  • WFH-480D Patient Debriefing rev 8-11-22
  • WFH-480E Staff Debriefing Form effective 5-20-2024
  • WFH-494 Incident Report Code Definitions
  • WFH-494 Incident Report rev 7-1-21
  • WFH-605 CMS S-R Death Rpt Wksheet June 2005 rev. 12-16-09 rev. 5-1-18
  • WFH-636 Hospital Restraint-Seclusion Death Report

Download FDA 3500A Medwatch Form (PDF)

Visitation rules and forms specifically for Dutcher Hall, the lesser restrictive unit of Whiting Forensic Hospital.

Download Files (PDF)

This section contains the following items:

  • Appendix 3.8.7.c - Dutcher Visitor Authorization Form
  • Dutcher General Rules for Patient Visitation
  • Dutcher Procedure 5.2 Visitors
  • Dutcher Visitors Log
  • Prohibited Items
  • WFH-121 Dutcher Special Patient Community Trip - Family Visit Recommendation 9.27.18
  • WFH-123 Dutcher Release of Responsibility for Minor Children rev. 2-14-22
  • WFH-124 Dutcher Visitor Authorization Form rev. 2-14-22
  • WFH-627 Off-Grounds Treatment Activity Form rev 3-12-19

This section contains Whiting Forensic Hospital leadership documents.

Download Files (PDF)

This section contains the following items:

  • WFH Governing Body By-Laws Approved 12.13.2021, signed
  • WFH Hospital Committees 12-22
  • WFH Hospital Committees 9-23
  • WFH Performance Improvement Plan rev 11-13-23
  • WFH Quality Indicators and Benchmarks (FY24) rev. 8-21-23

This section contains blank forms patients sign to release medical information.

Download Files (PDF)

The section contains the following items:

  • WFH-184 Release Information Form rev 5-1-18 Eng Spa
  • WFH-587 CLRP Release
  • WFH-630 DDS Authorization for Use and Disclosure of PHI

This section contains definitions of DMHAS acronyms.

Download File - DMHAS Acronyms Rev 6-14-24