Limited Supervision Reporting
SO Limited 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
Has a PO
1)*
Yes
2)
Yes
3)
Yes
4)
Yes
5)
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)
Date of Birth(mm/dd/yyyy):
Address
(street,city,state,zip):
Phone
(Numbers only):
Person Two
Full Name:
Date of Birth(mm/dd/yyyy):
Address
(street,city,state,zip):
Phone
(Numbers only):
Personal contact information
Input only numbers for phone numbers
Home Phone:
Cell Phone:
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)
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:
Treatment/Conditions
Date you last attended
treatment in person (mm/dd/yyyy):
Provider's name
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
No
Do you feel Hopeless or Helpless?
Yes
No
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 *
1 + 8 =
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