SO Activity Request and Safety Plan

ClientInformation
Name(Last)
(First)
IDOC#
SupervisingPPO
Address
Phone
CrimeofConviction
Treatment Completed
Yes
No
ActivityInformation
BeginDate:
One-time
Ongoing
LocationName,Address,andPhone #:
Chaperone Required:
Yes No
Name:
Activity(s) to be permitted:
Methodof travel: N/A
Whowillbeatthelocation? N/A
Whowillhaveknowledgeofyourcrime? N/A
Isthereanypotentialyourvictimwillbepresent? Yes No
Isthereanypotentialforunplannedcontactwithminors? Yes No
Parameters: Is a Safety Plan required?Yes No
Is the Sex Offender Supervision Activity RequestSafetyPlan complete and appropriate?YesNo
Has this been discussed with the client’s sex offender treatment provider?
Yes No N/A _____________________________________________
Treatment Provider Signature and Date (if required):
_______________________________________________
Client Signature and Date:
*I understand this activity addendum may be revoked at any time by any IDOC staff member.
IDOCApproval
SupervisingPPOComments:Classification level: ApprovedDenied
Approving AuthorityComments:Classification level: ApprovedDenied
SupervisingPPO’sSignatureand Date:
Approving AuthoritySignatureandDate:Howareyougoingtoavoidunnecessaryphysicalcontactwithaminor?Howareyougoingtoavoidbeing leftalonewithaminor? Howareyougoingtoavoidunnecessaryconversationswithaminor?How
will you remove yourself from a high-risk situation? Whatareyour chaperone’s responsibilities?
_________________________________________________________
Client SignatureDate
_________________________________________________________
Chaperone SignatureDate
_________________________________________________________
Officer SignatureDate