SOP 107.05-att-1: Program Data Form (Attachment 1)

SOP 107.05
Attachment 1

5/12/22
Page 1 of 2

|Georgia Department of Corrections Office of Reentry Services PROGRAM DATA FORM|Col2|Col3|Col4|Col5|Col6|Col7|Col8|
|---|---|---|---|---|---|---|---|
|SITE:|SITE:|SITE:|SITE:|SITE:|SITE:|SITE:|SITE:|
|FACILITATOR:|FACILITATOR:|FACILITATOR:|FACILITATOR:|FACILITATOR:|FACILITATOR:|FACILITATOR:|FACILITATOR:|
|GROUP NAME:|GROUP NAME:|GROUP NAME:|GROUP NAME:|GROUP NAME:|GROUP NAME:|GROUP NAME:|GROUP NAME:|
|Date Submitted:
|Date Submitted:
|Date Submitted:
|Date Submitted:
|Date Submitted:
|Date Submitted:
|Date Submitted:
|Date Submitted:
|
||Identification
Number
|Participant Name
(Last, First)|
Start Date |Termination
Reason|Pre-Test
Score|Post-Test
Score|Termination
Date|
||_1234567890_|_Smith, Johnny Ray_|_7-01-03_||||_01-28-04_|
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|Instructions:|Instructions:|Instructions:|Instructions:|Instructions:|Instructions:|Instructions:|Instructions:|
|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|Group facilitators must complete this form upon starting a new group. The participant’s name must be the exact name as listed by the GDC.
The identification number must be the assigned GDC number for offenders (State Prisons and Transitional Centers). The start date must be
entered as the first official day of class. The termination date for each participant must be the last date they attended class. The termination code
should be an applicable code (refer to page two).|
|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|The Operations Analyst/Designee or other staff member who makes SCRIBE data entries must be given a copy of this form to enter information
into SCRIBE. Facilitators are to forward this form to the OA each time there is a change of offender class status. The OA will enter the data and
indicate date entered, initial, and return the form to the group facilitator within seven (7) days of receipt.|
|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|The SSPC will review this form during QA Evaluations and/or site visits.|

Date Entered: _____________________________________ OA Initials: ______________________

Classification Chair Signature: ________________________________ Date Reviewed: __________________________

Retention Schedule: Upon completion, this form shall be maintained on site for at least one (1) year or upon review by the Social
Services Program Consultant (SSPC).

SOP 107.05
Attachment 1

5/12/22
Page 2 of 2
# Georgia Department of Corrections Office of Reentry Services PROGRAM DATA FORM

END REASONS

Retention Schedule: Upon completion, this form shall be maintained on site for at least one (1) year or upon review by the Social
Services Program Consultant (SSPC).