My WebLink
|
Help
|
About
|
Sign Out
Browse
Search
Sex Offender Supervision Activity Request
IDOC
>
Policies & Forms
>
Forms
>
Sex Offender Supervision Activity Request
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
12/20/2019 2:23:37 PM
Creation date
11/28/2017 12:10:11 PM
Metadata
Fields
Template:
Policies & Forms
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
2
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
Download electronic document
Show annotations
View images
View plain text
Offender Information <br />Name (Last) <br /> (First) <br />IDOC# <br />Supervising PPO <br /> <br />Address <br />Phone <br /> <br />Crime of Conviction <br />Treatment Provider <br /> <br />Treatment Fee Balance <br />COS Balance <br />Child Support Balance <br />Restitution Balance <br /> <br /> <br />Polygraph History <br />Sentencing and/or Parole Date: <br />Full Disclosure <br />Date: <br /> Maintenance Date: <br />Last ComplianceDate: <br /> <br />Activity Information <br />Begin Date: <br />End Date: <br />Location Name, Address, and Phone #: <br /> Chaperone: <br /> <br />Purpose of activities (or describe the activities): <br /> <br /> <br />Method of travel: <br /> <br />Who will be at the location? <br /> <br />Who will have knowledge of your crime? <br /> <br />Is there any potential your victim will be present? <br /> <br />Is there any potential for unplanned contact with minors? <br /> <br />Comments: <br /> <br />Treatment Provider’s Approval <br />Are the polygraph and fee balance information shown above correct? <br />Yes No <br />Is the Sex Offender Supervision Activity Request Safety Plan complete and appropriate? <br />Yes No <br />Is the chaperone appropriate for this activity? <br />Yes No <br />Has the offender missed appointments or assignments in the last 90 days? <br />Yes No <br /> <br />Other Comments: <br /> <br />Treatment Provider’s Signature: <br /> <br />
The URL can be used to link to this page
Your browser does not support the video tag.