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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 Compliance Date: <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 />