9 CRR-NY App. H-5NY-CRR

OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 9. EXECUTIVE DEPARTMENT
9 CRR-NY App. H-5
9 CRR-NY App. H-5
ACTIVITIES AND SCHEDULE REPORT
Probation Case No. ___
DACC Case No. ___
Probation Dept. ________
DACC FACILITY ___________
IDENTIFICATION DATA:
1. Name of probationer
 
Last Middle First
2.
S. S. No.
___________
3. Male
 
Female
4.
Street Address
___________
5. Apt. No.
 
6.
City
___________
7. State/Zip
 
8.
Sentence Date
_____
 
9. Maximum expiration date_____
10. In-patient care—admission date
___
 
11. Max. expiration ___
PROGRAM ACTIVITIES AND SCHEDULE: (Circle one)
12. Initial response to program:
 
favorable
 
unfavorable
undetermined
 
13.
Understanding of the treatment program:
 
good
 
poor
 
average
undetermined
14.
Participation in the program:
 
favorable
 
unfavorable
 
undetermined
15. Special considerations: (Circle one)
 
a.
Medical-- Yes
 
No
 
b. Adjustment to program-- Yes
 
No
c. Briefly explain
 
16. Anticipated length of stay:
 
1 year
 
3 mos.
 
TENTATIVE AFTERCARE PLANS:
17. Residence
 
18. Employment
 
19. Other
 
Signature
____________
Title
 
Date ________
9 CRR-NY App. H-5
Current through September 15, 2021
End of Document