SOP 215.22-att-1: Transitional Resident Data Form

Division:
Facilities
Effective Date:
January 23, 2020
Reference Code:
IID05-0003
Topic Area:
215 Policy-Transitional Center
PowerDMS:
View on PowerDMS
Length:
320 words

Summary

This is a comprehensive intake and assessment form used to document key information about residents admitted to transitional centers. The form captures demographic data, offense history, work and educational background, medical and mental health information, substance abuse history, and support systems for incarcerated individuals transitioning to release. It serves as an official institutional record maintained in each resident's file.

Key Topics

  • transitional center
  • resident intake
  • data collection form
  • offense history
  • educational assessment
  • medical profile
  • work history
  • substance abuse assessment
  • support systems
  • pre-release planning
  • rehabilitation
  • disciplinary record
  • probation information

Full Text

SOP 215.22
Attachment 1

1/23/20
Page 1 of 3

TRANSITIONAL RESIDENT DATA FORM

CENTER & RELEASE DATE

Counselor: __________________________ Name: ____________________________________

Status: PR PBR MRD RW True Name: ________________________________

Date Arrived: ________________________ Other Alias: ________________________________

Time Served At Arrival: ___________________________________________________________

Received From: _______________________ Number: __________________ DOB: ___________

Sentence Begin Date: __________________ FBI #: ____________________ SSN: ___________

MRD: __________/ SEC. STA. _________ Age At Arrest: _____________ Card: ___________

TPM: __________/ PBR RPT. DUE ______ HT: ______WT: _____Eyes: ______Hair:________

Class Begins: _______/Ends: ________WR Begins: __________Race: __________Sex:________

═══════════════════════════════════════════════════════
OFFENSE

|CURRENT OFFENSES|SENTENCE|COUNTY|
|---|---|---|
||||
||||
||||
||||

|PROBATION TO FOLLOW|COUNTY|LENGTH|
|---|---|---|
||||
||||
||||
||||

Rap Partners: ____________________________________________________________________

Victims: ________________________________________________________________________

Driver’s License: _________________________________________________________________

# Prior Felony Convictions: ________ Nature of Priors: __________________________________

Disciplinaries: #VIO ________ #NON VIO ________LAST _______ TPM EXT REC:_________

Escapes: ________________________________________________________________________

****************

Retention Schedule: Upon completion, this form shall be placed in the resident’s institutional file and will be
maintained according to the official retention schedule for institutional files.

WORK

SOP 215.22
Attachment 1

1/23/20
Page 2 of 3

|IN PRISON|ON STREETS|SKILLS|
|---|---|---|
||||
||||
||||
||||

Longest Single Job: _______________________________________________________________

How Long: ______________________________________________________________________

REHABILIATION/ED

Education: GRD_____GED_____COL_____VOC_____SPED_____IQ____ TEST________

Date:_______________________________________________________________________

|ENTRY
TEST|WRAT
R|A/M|WR/SP|DATE|IQ|TEST|DATE|
|---|---|---|---|---|---|---|---|
|
LATEST
RESTEST||||||||
|
||||||||

Entry Test: WRAT R ___________ A/M ___________ WR/SP _________ DATE ___________

Program Participation While In Prison: _______________________________________________

****************

MEDICAL

MEDICAL PROFILE : P ____ U ____ L ____ H ____ E ____ S ____ DATE: ____________

Medication: ____________________________________________________________________

Chronic Illness or Disability: _______________________________________________________

In Emergency Notify: _____________________________________________________________

Personal Physician: ______________________________________________________________

Psych Hospital: Outside: ____________ Inside: ______________ Diagnostic: _______________

****************

Retention Schedule: Upon completion, this form shall be placed in the resident’s institutional file and will be
maintained according to the official retention schedule for institutional files.

SOP 215.22
Attachment 1

1/23/20
Page 3 of 3

SUBSTANCE

Drugs: EXP AB DEP

During Offense: Yes No Types: ____________________________

Alcohol: NON. SOC. PROB AB REP During Offense: Yes No

****************

SUPPORT SYSTEMS

Married: _______ Separated: ________ Divorced: _______ Children #: _______ Never: ______

Home: __________________________________________ To Return: Yes No

Residence Plan: With Whom _____________________________________________________

Address: _____________________________________________________________________

Other Support:________________________________________________________________

****************

______________________________________ __________________
Counselor’s Signature Date

______________________________________ __________________
Resident’s Signature Date

Additional Information: __________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Retention Schedule: Upon completion, this form shall be placed in the resident’s institutional file and will be
maintained according to the official retention schedule for institutional files.

Attachments (4)

  1. Transitional Resident Data Form (320 words)
  2. Employer Job-Site Visits Form (172 words)
  3. Transitional Center Employment Agreement (545 words)
  4. Out of State Work Travel Permit (717 words)
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