Attachment G Baseline Person Tracking Info Form

OMB No. 0930-0277

Expiration Date: 05/31/2009

The CMHS Jail Diversion

Targeted Capacity Expansion Initiative

person tracking program information form *

revised MAY 2006

*DO NOT SUBMIT THIS FORM TO THE TAPA CENTER - FOR SITE USE ONLY.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0277.  Public reporting burden for this collection of information is estimated to average 1,373 hours per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

1. Site Code: ___ ___ 2. Study ID: ___ ___-___ ___ ___ ___ ___ [Enter site code and program # ONLY]

(Site Code)(Prog#) (Subject ID#)

3. Study Status (check one):  Active  Completed  Dropped  Refused Consent  Pending

4. Informed Consent Date: __ __/__ __/__ __ __ __

5. Informed Consent Status (check one):  Granted  Refused [If Refused, Skip to #9]  Pending

**ONLY COMPLETE QUESTIONS 6-8 IF INFORMED CONSENT WAS GRANTED**

6. Name: ____________ ___________ ___________ ________________ ___________________

(First) (Middle) (Last) (Maiden) (Alias)

7. Date of Birth: __ __/__ __/__ __ __ __

8. Address as of: __ __/__ __/__ __ __ __

Street Address: __________________________

City/State/Zip: ___________________/________/________

Day Phone: (___ ___ ___) ___ ___ ___-___ ___ ___ ___ Ext. ___ ___ ___

Evening Phone: (___ ___ ___) ___ ___ ___-___ ___ ___ ___ Ext. ___ ___ ___

Address as of: __ __/__ __/__ __ __ __

Street Address: __________________________

City/State/Zip: ___________________/________/________

Day Phone: (___ ___ ___) ___ ___ ___-___ ___ ___ ___ Ext. ___ ___ ___

Evening Phone: (___ ___ ___) ___ ___ ___-___ ___ ___ ___ Ext. ___ ___ ___

9. Age: ___ ___ 10. Sex (check one):  Male  Female  Other

11A. Hispanic or Latino(a):  Yes  No

11B. Race (select one or more):

 American Indian  Alaska Native  Asian Black or African American

 Hawaiian Native/Other Pac Islander  White

12. Primary Diagnosis (check one):

 PTSD  DESNOS  Other Axis II  Schizophrenia Spectrum

 Bipolar Disorder  Depressive Disorder  Substance Use Disorder

 Pending  Other (specify): ______________________________

13. Target Arrest/Incident Date: __ __/__ __/__ __ __ __

14. Most Serious Charge (check one):

 Drug Offenses  Minor Offenses  Property Offenses

 Other Crime Against Person  Potentially Violent Offense  Violent Offenses

 Sex Offenses  Pending

15. Charge Level (check one):

 Misdemeanor  Felony  Violation  Technical Violation  Pending

16. Release Date (if applicable): __ __/__ __/__ __ __ __ [If Not Applicable, enter 01/01/2001]

17. Date Enrolled in Program: __ __/__ __/__ __ __ __

18. Diversion Point (check one):

 Pre-booking  Post-booking  Parole/probation violation  Pending

19. Condition of Diversion:

 Charges dropped  Charges not filed  Condition of bail

 Deferred prosecution  Condition of probation  Deferred sentencing

 Pending  Other (specify): _________________________________

20. Spanish Interview

 Yes  No

**ONLY COMPLETE CONTACTS IF INFORMED CONSENT WAS GRANTED**

CONTACTS:

Name: Name:

Phone Number: Phone Number:

Comments: Comments:

OTHER COMMENTS:

TAPA Center, May 2006