Limited Supervision Reporting

DEC Monthly Report

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* = Field is required

*Last Name: Required

*First and Middle Name: Required

*SID Number: Invalid Required SIDs Don't Match

*Retype SID Number: Invalid

*Parole Officer's Name Required

Home Address

*Street 1:(If homeless, put Homeless in the line below)Required

Street 2:

City:

State:
Oregon

Zip Code: Invalid

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: Invalid

Who Lives With You

Name:(Enter N/A on line 1 if you live alone)Required

Relationship

Age

Has a PO

1)*

Yes

Significant Other's Name*

Required

If no significant other enter NONE

Do you have an open DHS case?
Yes No

Caseworker Name

Caseworker Phone Invalid

Next Juvenile Court Date (mm/dd/yyyy):Invalid

Personal contact information*

Input only numbers for phone numbers

Home Phone: Invalid

Cell Phone: Invalid

Message Phone: Invalid

Explanation if no phones

Email: Invalid

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)Required

Street 1:

Street 2:

City:

State:
Oregon

Zip Code: Invalid

Provide supervisor name with phone or email:

Supervisor's Name:

Email: Invalid

Phone: (Numbers only) Invalid

Work Schedule:

Hours/Week:

Monthly Income: (Numbers only) Invalid

If not working, how are you financially supported?

Education

Name of School Attending:

Street 1:

Street 2:

City:

State:
Oregon

Zip Code: Invalid

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):Invalid

Date last attended treatment (mm/dd/yyyy):Invalid

Treatment graduation date (mm/dd/yyyy):Invalid

Sobriety Date (mm/dd/yyyy):Invalid
(Congratulations!!!)

Drug of Choice:

Medical/Mental Health Provider

Provider Phone: Invalid

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):Invalid
(Congratulations!!!)

Birth Control
Yes No

Birth Control Type

Doing Community Service?
Yes No

Community Service hours remaining (numbers only): Invalid

Date last worked (mm/dd/yyyy):Invalid

Paid court fees/fines (numbers only)?
Yes No

Amount Paid fees/fines (numbers only):Invalid

Date Paid (mm/dd/yyyy): Invalid

Paid supervision Fees?
Yes No

Amount Paid supervision fees (numbers only):Invalid

Date Paid (mm/dd/yyyy): Invalid

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 *

1 + 6 =

Required

SID Required SID Invalid SIDs Don't Match Zip Code Invalid Mailing Address Zip Code Invalid Home Phone Invalid Cell Phone Invalid Message Phone Invalid Employer Zip Code Invalid School Address Zip Code Invalid School Hours/Term Invalid Community Service Remaining Invalid Community Service Invalid Invalid Supervision Fees Paid Invalid Supervision Fees date Paid Invalid Parole Officer's Name Required Last Name Required First Name Required Home Address Required

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