Limited Supervision Reporting
DEC Monthly Report
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* = Field is required
*Last Name:
*First and Middle Name:
*SID Number:
*Retype SID Number:
*Parole Officer's Name
Home Address
*Street 1:(If homeless, put Homeless in the line below)
Street 2:
City:
State:
Oregon
Zip Code:
If homeless please give a description of where you are at!
Different mailing address
Mailing Address
Street 1:
Street 2:
City:
State:
Oregon
Zip Code:
Who Lives With You
Name:(Enter N/A on line 1 if you live alone)
Relationship
Age
Has a PO
1)*
Yes
2)
Yes
3)
Yes
4)
Yes
5)
Yes
Significant Other's Name*
If no significant other enter NONE
Do you have an open DHS case?
Yes
No
Caseworker Name
Caseworker Phone
Next Juvenile Court Date
(mm/dd/yyyy):
Personal contact information*
Input only numbers for phone numbers
Home Phone:
Cell Phone:
Message Phone:
Explanation if no phones
Email:
Drivers License Information
Do you have a valid driver’s license?
Yes
No
Driver’s License Number
Vehicle Information
Make/Model of vehicle you drive:
Color
License Plate:
Employment
Name of Business:* (Enter UNEMPLOYED if not working)
Street 1:
Street 2:
City:
State:
Oregon
Zip Code:
Provide supervisor name with phone or email:
Supervisor's Name:
Email:
Phone: (Numbers only)
Work Schedule:
Hours/Week:
Monthly Income: (Numbers only)
If not working, how are you financially supported?
Education
Name of School Attending:
Street 1:
Street 2:
City:
State:
Oregon
Zip Code:
Term Schedule:
Hours/Term:
Alcohol and Drug Treatment and Medical/Mental Health
Substance Abuse
Past
Present
Alcohol and Drug Treatment Provider
Name of treatment counselor
Date you began treatment (mm/dd/yyyy):
Date last attended treatment (mm/dd/yyyy):
Treatment graduation date (mm/dd/yyyy):
Sobriety Date (mm/dd/yyyy):
(Congratulations!!!)
Drug of Choice:
Medical/Mental Health Provider
Provider Phone:
Diagnosis
Taking Medication
Yes
No
List all Medication & Doses (A-Z, 0-9, space, comma, period and question mark only.)
Currently Pregnant?
Yes
No
Due Date (mm/dd/yyyy):
(Congratulations!!!)
Birth Control
Yes
No
Birth Control Type
Doing Community Service?
Yes
No
Community Service hours remaining (numbers only):
Date last worked (mm/dd/yyyy):
Paid court fees/fines (numbers only)?
Yes
No
Amount Paid fees/fines (numbers only):
Date Paid (mm/dd/yyyy):
Paid supervision Fees?
Yes
No
Amount Paid supervision fees (numbers only):
Date Paid (mm/dd/yyyy):
Comment to PO...
By checking this box I certify the above information is true and I am the person named above (or a legal representative)
Math Question *
8 + 9 =
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