Statutes, codes, and regulations
New York Codes, Rules and Regulations
Title 9 - EXECUTIVE DEPARTMENT
Appendices
Appendix H-5

N.Y. Comp. Codes R. & Regs. tit. 9, Appendices, app H-5

Download
PDF
Current through Register Vol. 46, No. 36, September 4, 2024
Appendix 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 ________

N.Y. Comp. Codes R. & Regs. tit. 9, Appendices, app H-5