SOP_NUMBER: 215.22-att-1
TITLE: Transitional Resident Data Form
REFERENCE_CODE: IID05-0003
DIVISION: Facilities
TOPIC_AREA: 215 Policy-Transitional Center
EFFECTIVE_DATE: 2020-01-23
WORD_COUNT: 320
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/106253
URL: https://gps.press/sop-data/215.22-att-1/
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
ATTACHMENTS:
1. Transitional Resident Data Form
URL: https://gps.press/sop-data/215.22-att-1/
2. Employer Job-Site Visits Form
URL: https://gps.press/sop-data/215.22-att-2/
3. Transitional Center Employment Agreement
URL: https://gps.press/sop-data/215.22-att-3/
4. Out of State Work Travel Permit
URL: https://gps.press/sop-data/215.22-att-4/
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FULL TEXT:
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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|
|---|---|---|
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||||
||||
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|PROBATION TO FOLLOW|COUNTY|LENGTH|
|---|---|---|
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||||
||||
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Rap Partners: ____________________________________________________________________
Victims: ________________________________________________________________________
Driver’s License: _________________________________________________________________
# Prior Felony Convictions: ________ Nature of Priors: __________________________________
Disciplinaries: #VIO ________ #NON VIO ________LAST _______ TPM EXT REC:_________
Escapes: ________________________________________________________________________
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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|
|---|---|---|
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||||
||||
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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: _______________________________________________
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**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: _______________
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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
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**SUPPORT SYSTEMS**
Married: _______ Separated: ________ Divorced: _______ Children #: _______ Never: ______
Home: __________________________________________ To Return: Yes No
Residence Plan: With Whom _____________________________________________________
Address: _____________________________________________________________________
Other Support:________________________________________________________________
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______________________________________ __________________
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.