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New York Codes Rules Regulations (Last Updated: March 27,2024) |
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TITLE 9. Executive Department |
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Appendices |
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Appendix H-5. |
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ACTIVITIES AND SCHEDULE REPORT Probation Case No. ___ DACC Case No. ___ Probation Dept. ________ DACC FACILITY ___________ IDENTIFICATION DATA: 1. Name of probationer Last Middle First 2. S. S. No. ___________ 3. Male Female 4. Street Address ___________ 5. Apt. No. 6. City ___________ 7. State/Zip 8. Sentence Date _____ 9. Maximum expiration date_____ 10. In-patient care—admission date ___ 11. Max. expiration ___ PROGRAM ACTIVITIES AND SCHEDULE: (Circle one) 12. Initial response to program: favorable unfavorable undetermined 13. Understanding of the treatment program: good poor average undetermined 14. Participation in the program: favorable unfavorable undetermined 15. Special considerations: (Circle one) a. Medical-- Yes No b. Adjustment to program-- Yes No c. Briefly explain 16. Anticipated length of stay: 1 year 3 mos. TENTATIVE AFTERCARE PLANS: 17. Residence 18. Employment 19. Other Signature ____________ Title Date ________ |