Form Arrest Data Collec Arrest Data Collec Arrest Data Collection Form

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

CMHS Jail Diversion and Trauma Recovery Initiative
Priority to Veterans

ARREST DATA COLLECTION 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 10 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.

Arrest Form 2.19.09

Page 1 of 11

Date of Baseline Interview: ___ ___/ ___ ___/ ___ ___ __ ___
Study ID #
____ ____-____- ___ -____ ____ ____
(Site Code) (Prog #) (Grp #) (Subject ID #)

Target Arrest/Incident
INSTRUCTIONS
This section is to record the Target Arrest/Incident that facilitated the client’s entry into the Jail
Diversion Program. Please record the information following the instructions below.
(1) Record the ‘Target Arrest/Incident’ date in the Target Arrest table below.
(2) Determine the most serious charge. Most serious charge is determined by the charge that
caries the most severe or maximum penalties in your state. Please describe the charge.
(3) Use the codes on page 10 to determine the specific charge code and circle the charge level.
**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.***
(4) Indicate if the target arrest/incident includes a drug or alcohol related charge, if known.
(5) Indicate if the arrest includes a domestic violence related charge if known. That is, a charge
against person where the victim is a current or former intimate, family member or relative.
(6) If there is jail time associated with this charge, please enter the dates of jail admission and
jail release or total jail days served, and indicate the reason for the incarceration.

Target Arrest/Incident
TAR1

Target Arrest/Incident Date

____ ___/____ ____/ ____ ____

TAR2

Most Serious charge -or charge most likely to
be pursued if individual was arrested.
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
6 No Formal Charge
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

TAR3
TAR4

Most Serious Charge:
__ __
Does this arrest/incident include a drug/alcohol
related charge? (circle one)
Does this arrest/incident include a crime against
a current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

__ ___ ___

___ ___/___ ___/___ ___

TAR5
2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

IF Client was arrested on a technical violation, please be sure that the original or underlying arrest for
the violation is documented in the PRIOR Arrests.
Arrest Form 2.19.09

Page 2 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

PRIOR 12- MONTH ARREST HISTORY
INSTRUCTIONS
This section is to record Arrests that have occurred in the 1 year PRIOR to the Target Arrest/Incident
Date. Record prior arrests using one box for each arrest. If more than seven (7) prior arrests have
occurred, record this additional arrest information by photocopying and completing a blank page for
each additional prior arrest.
1. Period of Interest: ___ ___/___ ___/___ ___ ___ ___ to ___ ___/___ ___/___ ___ ___ ___
[1 year prior to the Target Arrest/Incident Date]

[day before the Target Arrest/Incident Date]

2. Total number if Arrests in Prior 12 months (period above): ___ ___ ___
3. Was the Individual incarcerated on the date one year prior the Target Arrest? 1. Yes 2. No
4. If yes, please indicate the number of consecutive jail days for this incarceration: ___ ___ ___
Please complete the Prior Arrest Tables following the same instructions as the Target Arrest. Be
sure to enter all charge codes for ‘Most serious charge’ using the charge code list on page 10.

NOTE: Violations/infractions for which a court appearance ticket is issued (but no arrest occurs) should also
be recorded. Therefore, for purposes of this form “Arrest” includes any charge.

PRIOR ARREST 1

PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
6 No Formal Charge
1. Yes
7. DK
2. No
8. Missing

Most Serious Charge:

___ ___

PRE3

Does this arrest include a drug/alcohol related
charge? (circle one)

PRE4

Does this arrest include a crime against a
1. Yes
7. DK
current or former intimate or family
2. No
8. Missing
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release
# Jail Days
Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
1. ___ ___/___ ___/___ ___
___ ___/___ ___/___ ___ __ ___ ___
3- Sanction for noncompliance

PRE5

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Arrest Form 2.19.09

1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

Page 3 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

PRIOR ARREST 2
PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

PRE3
PRE4

Most Serious Charge:
___ ___
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

PRE5

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

PRIOR ARREST 3
PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

PRE3
PRE4

Most Serious Charge:
___ ___
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

PRE5

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
Page 4 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

PRIOR ARREST 4
PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

PRE3
PRE4

Most Serious Charge:
___ ___
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

PRE5

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

PRIOR ARREST 5
PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

PRE3
PRE4

Most Serious Charge:
___ ___
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

PRE5

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
Page 5 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

PRIOR ARREST 6
PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

PRE3
PRE4

Most Serious Charge:
___ ___
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

PRE5

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

PRIOR ARREST 7
PRE1

Date of Prior Arrest

____ ___/____ ____/ ____ ____

PRE2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

PRE3
PRE4

Most Serious Charge:
___ ___
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

PRE5

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
Page 6 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

POST 12- MONTH ARREST HISTORY
INSTRUCTIONS
This section is to record all arrests in that have occurred in the 1 year POST the Target
Arrest/Incident Incarceration Release date. That is the date that the client was last released from jail
for the Target Arrest. Record post arrests from that date using one box for each arrest. If more than
seven (7) post arrests have occurred, record this additional arrest information by photocopying and
completing a blank page for each additional post arrests.
1. Please indicate the jail release date for the Target Arrest: ___ ___/ ___ ___/ ___ ___ ___ ___
2. Period of Interest: ___ ___/___ ___/___ ___ ___ ___ to ___ ___/___ ___/___ ___ ___ ___
[Target Arrest Release Date]

[1 year after the Target Arrest Date]

2. Total number if Arrests in Period defined above: ___ ___ ___
Please complete the POST Arrest Tables following the same instructions as the Target Arrest. Be
sure to enter all charge codes for ‘Most serious charge’ using the charge code list on page 10

NOTE: Violations/infractions for which a court appearance ticket is issued (but no arrest occurs) should also
be recorded. Therefore, for purposes of this form “Arrest” includes any charge.

POST ARREST 1
POS1

Date of POST Arrest

____ ___/____ ____/ ____ ____

POS2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

POS3
POS4

POS5

Most Serious Charge:
__ __
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

Page 7 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

POST ARREST 2
POS1

Date of POST Arrest

____ ___/____ ____/ ____ ____

POS2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

POS3
POS4

POS5

Most Serious Charge:
__ __
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

POST ARREST 3
POS1

Date of POST Arrest

____ ___/____ ____/ ____ ____

POS2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

POS3
POS4

POS5

Most Serious Charge:
__ __
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
Page 8 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

POST ARREST 4
POS1

Date of POST Arrest

____ ___/____ ____/ ____ ____

POS2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

POS3
POS4

POS5

Most Serious Charge:
__ __
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

POST ARREST 5
POS1

Date of POST Arrest

____ ___/____ ____/ ____ ____

POS2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

POS3
POS4

POS5

Most Serious Charge:
__ __
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

Page 9 of 11

Study ID #

OMB No. 0930-0277
Expiration Date: 05/31/2009

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

POST ARREST 7
POS1

Date of POST Arrest

____ ___/____ ____/ ____ ____

POS2

Most Serious charge
(Literal, describe in words)
_____________________________
_____________________________

Charge Level (circle one)
1 Felony
2 Misdemeanor
3 Violation/Ticket/Infraction (Lower than Misdemeanor)
4 Technical Violation (Probation/Parole)
5 Unspecified
1. Yes
7. DK
2. No
8. Missing
1. Yes
7. DK
2. No
8. Missing

POS3
POS4

POS5

Most Serious Charge:
__ __
Does this arrest include a drug/alcohol related
charge? (circle one)
Does this arrest include a crime against a
current or former intimate or family
member/relative? (circle one)
Date of Jail Admission
Date of Jail Release

# Jail Days

1. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

__ ___ ___

2. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

3. ___ ___/___ ___/___ ___

___ ___/___ ___/___ ___

___ ___ ___

Arrest Form 2.19.09

Reason for Incarceration
(circle all that apply)
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance
1- Pretrial detention
2- Sentence
3- Sanction for noncompliance

Page 10 of 11

Study ID #

____ ____-____- ___ -____ ____ ___
(Site Code) (Prog #) (Grp #) (Subject ID #)

OMB No. 0930-0277
Expiration Date: 05/31/2009

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

Arrest 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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