New York Codes, Rules and Regulations
Title 9 - EXECUTIVE DEPARTMENT
Appendices
Appendix H-5
Current through Register Vol. 46, No. 12, March 20, 2024
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)
16. Anticipated length of stay: 1 year 3 mos.
TENTATIVE AFTERCARE PLANS:
17. Residence ____________
18. Employment ____________
19. Other ____________
Signature ________ Title ____________
Date ________
