Form Event Tracking Scr Event Tracking Scr Event Tracking Screen

OMB No. 0930-0277
Expiration Date: XX/XX/XXXX

CMHS Jail Diversion and Trauma Recovery Initiative
Priority to Veterans

1: EVENT TRACKING INFORMATION FORM
INTIAL SCREENING FORM
2.19.09

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 18 minutes per
respondent, 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 2-1057, Rockville, Maryland, 20857.

Initial Screen Form 2.19.09

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CMHS Jail Diversion and Trauma Recovery Initiative- Priority to Veterans
********
Initial Screening Tracking Form
INSTRUCTIONS
This section is to record the point where the decision was made for the client to enter the Jail
Diversion Program. Please record the information following the instructions below.
(1) Record the Screening/Assessment Date in the table below.
(2) – (6) Record demographic information: Sex, Age, Veteran Status, Ethnicity, and Race.
(7) Record the category for the most serious charge. Most serious charge is determined by the
charge that caries the most severe or maximum penalties in your state. **
**If there is no charge (pre-booking diversion) please characterize the incident as the charge that
most likely would have been pursued if the individual had been formally arrested.**
(8) Indicate the Charge Level.
(9) Record the clients eligibility status for the diversion program at this time.
(10)If client is eligible, please indicate if they agree to enter the program at this time.
Comments- Please include all additional relevant information on the screening/assessment process
or the client’s status in the diversion program.

Site Code: ___ ___

Program Code: __ ___

Group Code: ____ ___

1

Initial Screening Date

2

Sex (circle one)

3

Age (DOB)

4

Served in US Military
(past or current)

5

Hispanic or Latino

2. Yes

6

Race (select one or more)

1. American Indian
2. Alaska Native
3. Asian

7

Most Serious charge Categoryor charge most likely to be
pursued if individual was
arrested.

8

Charge Level (circle one)

Initial Screen Form 2.19.09

____ ___/____ ____/ ____ ____
1. Male

2. Female

3. Other

____ ____ / ____ ____ ____ ____
(M M)
(Y Y Y Y)
1. Yes
2. No
2. No

4. Black or African American
5. Native Hawaiian or other Pacific
Islander
6. White
1. Crimes Against Persons 4. Alcohol or Drug Related Offense
(Violence)
5. Major Motor Vehicle (excluding
2. Crime Against Person
DUI/DWI)
Other
6. Public Order
3. Property Crime
7. Other, specify____________
1- Felony
2 -Misdemeanor
3 -Violation/Ticket/Infraction (Lower
than Misdemeanor)

4- Technical Violation
(Probation/Parole)
5- Unspecified
6 -No Formal Charge

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9

Eligibility (at this time)

9a.

If NOT Eligible- Circle all reasons that apply:
1- Not eligible, psychiatric criteria :
Explain:_______________
2- Not eligible, legal criteria
3- Not eligible, substance abuse criteria
4- Not eligible, released from jail

10

Complete only if “yes” to 9
Individual Agrees to Enter Diversion
Program at this stage

1. Yes, Eligible/Accepted
2. Eligible at this stage, referred for further evaluation.
Please specify where client was
referred:____________________________
3. Not Eligible (please indicate all reasons below)

5- Not eligible, not competent
6- Not eligible, location/jurisdiction of arrest
7- Not eligible, location of residence
8- Not eligible, dropped out of initial screening
9- Not eligible, other reason
Specify____________________
1. Yes
2. No

Comments:

Initial Screen Form 2.19.09

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CHARGE CODES FOR MOST SERIOUS CHARGE
Criminal Charge
Category
Crimes Against
Persons
(Violence)

Crime Against
Persons (Other)

Property Crime

Alcohol or DrugRelated Offenses
Major Motor
Vehicle
(excluding
DUI/DWI)

Public Order

Charge Description

Charge Code

Any homicide
Any attempted homicide
Sexual Assault, Indecent assault (not statutory rape)
Robbery
Kidnapping
Any Other Crime with Weapon
Assault, Assault and Battery
Other
Threats, harassment, annoying phone call, intimidation,
menacing
Violation of restraining/protective/no contact order
Statutory rape
Open and Gross/Lewdness
Other
Arson
Burglary/ breaking and entering
Larceny
Theft
Larceny by check/forgery
Fraud
Shoplifting
Other
Possession/Sale of Illicit Drugs
DUI/DWI
Intoxication/Open Container
Other
Reckless/ Negligent Driving
No registration/license/insurance
Other

101
102
103
104
105
106
107
108
201

Disorderly Conduct, Disturbing Peace, Affray, Melee
Loitering, Vagrancy, Trespassing
Resisting Arrest
Carrying concealed weapon/other firearm violation
Failure to appear in court, probation/parole violation, or
other court related charge
Other
Unspecified

601
602
603
604
605

Initial Screen Form 2.19.09

202
203
204
205
301
302
303
304
305
306
307
308
401
402
403
404
501
502
503

606
999

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