N.Y. Comp. Codes R. & Regs. tit. 7 § 1904.3
If an inmate who is participating in a continuous temporary release program receives a urinalysis or breathalyzer test that is positive for drugs or alcohol in violation of his memorandum of agreement, he may, after being reviewed and approved by the Temporary Release Committee (TRC) and the superintendent, in accordance with section 1904.2(i)-(k) of this Part, be given the opportunity to enter a relapse program for alcohol and substance abuse treatment. Participation in the Relapse Program will be based upon the inmate's consent to the following agreement:
RELAPSE PROGRAM AGREEMENT
I want to participate in the Relapse Program which is part of the Continuous Temporary Release Program. I understand that the results of a urinalysis/breathalyzer test dated __ constitute a violation of Departmental, institutional and/or temporary release program rules and regulations. I also understand that, based upon the subject test results, I would ordinarily be served with a misbehavior report alleging a violation of the Standards of Inmate Behavior and be referred to the Temporary Release Committee for a temporary release removal proceeding. I agree, however, to waive service of a misbehavior report and any disciplinary proceeding on this issue. I further agree to participate in the Department's Relapse Program for alcohol and substance abuse treatment. I understand that I will have only one opportunity to participate in the Relapse Program. I understand that I will be transferred to a general confinement facility in order to participate in the Relapse Program and that the Relapse Program will last approximately sixty days. I realize that, in some instances, the Program will be shorter. Thereafter, if I have successfully completed the Treatment Program, I will be returned to full participation in the continuous temporary release program.
I also understand and agree that I can be removed from the Relapse Program at any time in accordance with the provisions of section 1904.1. I further understand and agree that, if I am removed from the Relapse Program, I will not be reinstated to the continuous temporary release program. I also understand, however, that I may subsequently, reapply for participation in the continuous temporary release program pursuant to applicable Department eligibility requirements.
I have read and fully understand and agree to the above terms and conditions.
Date: ______ Inmate's signature ..........................................................................................
...................................................................................................................................................
Witness' signature
N.Y. Comp. Codes R. & Regs. Tit. 7 § 1904.3