Limited Supervision Reporting

SO Limited 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

Has a PO

1)*

Yes

Significant Other's Full Name & Date of Birth (or person(s) you have had any sexual/intimate contact with)

(if they live with you then add them to 'Who lives with you')
(if more than two use the comment area)

Person One

Full Name:* (If no significant other enter NONE)Required

Date of Birth(mm/dd/yyyy): Invalid

Address
(street,city,state,zip):

Phone
(Numbers only): Invalid

Person Two

Full Name:

Date of Birth(mm/dd/yyyy): Invalid

Address
(street,city,state,zip):

Phone
(Numbers only): Invalid

Personal contact information

Input only numbers for phone numbers

Invalid Home Phone:

Invalid Cell Phone:

Invalid Message Phone:

Explanation if no phones

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)

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:

Treatment/Conditions

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

Provider's name

Invalid Date Last Polygraph (mm/dd/yyyy):

With:

Violated Conditions
of Supervision/Treatment?
Yes No

Which ones?

Accessed Internet/phone apps
that PO has not approved?
Yes No

Which ones?

Masturbated more than
4 times within one week?

Yes

Do you feel Hopeless or Helpless?

Yes

Taking Medication
Yes No

Which ones?

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 *

7 + 8 =

Required

SID Required Parole Officer Name Required SID Invalid SIDs Don't Match Home Address Zip Code Invalid Mailing Address Zip Code Invalid Significant Other 1 DOB Invalid Significant Other 1 Phone Invalid Significant Other 2 DOB Invalid Significant Other 2 Phone Invalid Home Phone Invalid Cell Phone Invalid Message Phone Invalid Employer Address Zip Code Invalid Employer Supervisor Email Invalid Employer Supervisor Phone Invalid School Address Zip Code Invalid Treatment Attended Date Invalid Polygraph Date Invalid Last Name Required First Name Required

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