Traditional Probation & Intensive Supervision ... - Ottawa County

Probation Officer:DEMOGRAPHICS/SENTENCINGCourt Case No:Name:DOB:City of Residence:Gender: □ Male□ FemaleEthnicity:□ Caucasian □ African American □ Native American□ Hispanic/Latino □ Asian □ OtherMarital Status:□ Married □ Separated □ Divorced □ SingleLast Grade Completed:Employment Status:□ Full Time □ Part Time □ UnemployedType of Probation:□ Reporting □ Mail-In □ Non-ReportingBond-Out: □ Yes□ NoIncome at Time of Incarceration:Rate of Pay: Hours Per Week:Income at Time of Probation Discharge:Rate of Pay: Hours Per Week:SUBSTANCE ABUSE ASSESSMENT□ Yes □ NoADE Category (Alcohol): □ 1 □ 2 □ 3 □ 4 □ 5ADE Category (Drugs): □ 1 □ 2 □ 3 □ 4 □ 5PROBATION CONDITIONSNo Alcohol: □ Yes □ NoNo Drugs: □ Yes □ NoCounseling: □ Yes □ NoElectronic Monitoring: □ Yes □ NoISP: □ Yes □ NoDIVERSIONSJail: (Average Number of Days Diverted)Attachment F - PROBATION DATA COLLECTION FORMPROBATION INFORMATIONCharge:□ Domestic Violence □ MDOP□ OWI □ MIP□ Poss./Use Controlled Substance□ Retail Fraud□ DWLS□ Other (Specify)Probation Length (Months):Sentence Date:Probation Discharge Date:Satisfactory Discharge: □Unsatisfactory/Revoked: □Previous Offenses:Felony MiscellaneousPROBATION VIOLATIONDate Violation Code* DispositionOccurred□ Jail □ No Jail□ Jail □ No Jail□ Jail □ No Jail□ Jail □ No Jail□ Jail □ No Jail*PBT, DT, Curfew, New Offense, EMS, FTA, Tx/AA, OtherNew offense (Specify charge and date of offense):Charge : Date:New offense (Specify charge and date of offense):Charge : Date:New offense (Specify charge and date of offense):Charge : Date:Secondary Probation Officer:ISP & PROBATION CONTACTSHome OfficeDate Visit Visit PBT DT□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □□ □ □ □Updated: 01/26/06