Form Tracking Informati Tracking Informati Tracking Information Form

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

CMHS Jail Diversion and Trauma Recovery Initiative
Priority to Veterans

PERSON TRACKING PROGRAM INFORMATION FORM
2.19.09
*DO NOT SUBMIT THIS FORM TO THE AHP - 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 6 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.

DO NOT SUBMIT THIS FORM TO AHP - FOR SITE USE ONLY.
Person Tracking 2.19.09
Page 1

CMHS Jail Diversion and Trauma Recovery Initiative-Priority to Veterans
Baseline Person Tracking Program Information
1.

Study ID#:

2.

Study Status
(circle one)

3.

Informed Consent Date

4.

Informed Consent Status (circle one)

____ ____-____- ___ -____ ____ ____
(Site Code) (Prog #) (Grp #) (Subject ID #)
1. Active
2. Completed
3. Dropped

4. Refused Consent
5. Pending

____ _____/ _____ ____/ _____ ____ ____ ____
Month
Day
Year

1. Granted

2. Refused

3. Pending

***ONLY COMPLETE ITEMS 5-6 IF INFORMED CONSENT WAS GRANTED****
5.

Name:
_______________ ____________ ______________ ______________ _______________
First
Middle
Last
Maiden
Nickname

6.

Address

7.

Date of Birth

8.

Age

9.

Sex (circle one)

9.

Hispanic or Latino
(circle one)

1. Yes

2. No

10.

Served in US Military- past or current
(circle one)

2. Yes

2. No

11.

Race (select one or more)

Street:_________________________________________________
City/State/Zip: _________________________________________
Phone: _______________________ Cell Phone: ____________
____ _____/ ____ _____/ _____ ____ ____ ____
Month
Day
Year
______ ______
1. Male

2. Female

1. American Indian
2. Alaska Native
3. Asian

3.Other

4. Black or African American
5. Native Hawaiian or other Pacific
Islander
6. White

DO NOT SUBMIT THIS FORM TO AHP - FOR SITE USE ONLY.
Person Tracking 2.19.09
Page 2

12.

Primary Diagnosis
(circle one)

13.

Target Arrest/Incident Date

13.

Most Serious charge
Category-or charge most likely
to be pursued if individual was
arrested.
(circle one)

14.

Charge Level (circle one)

15.

Release date
(If Not Applicable, enter 01/01/2001)

16.

Date Enrolled in Program

17.

Diversion Point
(circle one)

18.

Condition of Diversion
(circle one)

19.

Spanish Interview
(circle one)

1.
2.
3.
4.

PTSD
DESNOS
Bipolar Disorder
Depressive Disorder

5. Other Axis II
6. Substance Use Disorder
7. Schizophrenia Spectrum
8. Pending
9 Other
(Specify:________________)

____ _____/ _____ ____/ _____ ____ ____ ____
Month
Day
Year
1. Crimes Against Persons
(Violence)
2. Crimes Against Persons
(Other)
3. Property Crime
1- Felony
2 -Misdemeanor
3 -Violation/Ticket/Infraction
(Lower than Misdemeanor)

4. Alcohol or Drug Related Offense
5. Major Motor Vehicle (excluding
DUI/DWI)
6. Public Order
7. Other, specify____________
4- Technical Violation
(Probation/Parole)
5- Unspecified
6 -No Formal Charge

____ _____/ _____ ____/ _____ ____ ____ ____
Month
Day
Year
____ _____/ _____ ____/ _____ ____ ____ ____
Month
Day
Year
1. Pre-booking
2. Post-booking

3. Parole/Probation Violation
4. Pending

1.
2.
3.
4.

5. Condition of Probation
6. Deferred Sentencing
7. Pending
8. Other: _________________

Charges Dropped
Charges not filed
Condition of Bail
Deferred Prosecution

1- Yes

2- No

**** Enter Contact Information into Tracking System******

DO NOT SUBMIT THIS FORM TO AHP - FOR SITE USE ONLY.
Person Tracking 2.19.09
Page 3