The image displays a form titled "INMATE COUNT" at the top left corner. The form includes fields for date, time, count type (morning, midday, evening), and count status (okay, incomplete). There are columns provided to list the inmate's number, name, cell location, and comments or notes about the inmate's condition or other pertinent information. The form appears to be a structured way for staff at a correctional facility to track the presence of inmates during specific timeframes.