FPS-C Former Prisoner Survey Consent

D

FORMER PRISONER SURVEY

Records Form

FORM FPS-1 U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS

Bureau of Justice Statistics

ate 03/30/07 OMB No. XXXXXXXX: Approval Expires XX/XX/XX

Reporting Instructions

Please complete one form for each sampled individual. The term, Parolee, is used to refer to any subject provided
in the sample. If the information is unavailable in the parole office’s files or you are unaware of the information, please check
the box for ‘Unknown.’

If you need assistance, please contact Tim Mulcahy at XXXX or XXXX at XXXX.

__ __ __ __ __ __ __ __ __ __ __ __

1. Case ID Number:

2. What is the parolee’s gender?

Male Female

3. What is the parolee’s date of birth?

		/			/
mm			dd			yyyy

or

Unknown, if Unknown go to 3b.

3

___ ___ ___

b. If date of birth is unknown, what is the parolee’s age?

or Unknown

4. Is the parolee of Hispanic or Latino origin?

Yes

No

Unknown

5. Which of these categories describes the parolee’s race? Mark all that apply.

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

Information not available

Burden Statement: Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number. The burden of this collection is estimated to average 5 minutes per response, including reviewing instructions, searching existing data sources, gathering necessary data, and completing the review form. Send comments regarding this burden estimate or any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531. Do not send your completed form to this address.

6. What was the parolee’s date of RELEASE TO PAROLE?

		/			/
mm			dd			yyyy

or
Unknown

7. What was the parolee’s date of ADMISSION TO PRISON?
   Include the last continuous period of confinement even if transferred. If the parolee was recommitted after escape or parole, only address the recommitment offense and time.

		/			/
mm			dd			yyyy

or
Unknown, if Unknown go to 7b.

7 b. If date of admission is unknown, what was the length of time last served in prison?

Months Years or
Unknown

8. How many contacts are required per month between the parolee and the parole office?

Number of Contacts or Unknown