CRC Screening Form

Type of Referral: Click to Select

Type of Referral:
Inmate Name:       IDOC#:      
Custody Level: Crime Severity:
PED       PHD       TPD      FTRD      (month/year)
LSI score       TCU score       Pathway <     
Escape Conviction:
Victim Alert/Notification:
Check all that apply
Expired Drivers License
Birth Certificate
Suspended Drivers License
Social Security Card
Valid Drivers License
Work Force Readiness -50 Hrs. Completed
Referral Recommendations - Check all that apply
East Boise-CRC
Twin Falls-CRC
Idaho Falls-CRC
Ada County Work Release-Male
Nampa-CRC
Ada County Work Release-Female
SICI-CRC
Comments:      
Case Manager & Assoc. #:      
Release Plan Destination:      
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I understand that completion of this screening form and meeting all placement criteria does not guarantee placement in a community work center.
Inmate’s SignatureIDOC #Date
********************Forward to Medical Provider for Screening********************
Medical Screening:
Medically Cleared for CWC
Cleared for food handling
No CWC Placement
End date: ___________________
Medical Staff Name SignatureDate
********************Forward to the Facility Move Coordinator********************
IDAHO DEPARTMENT OF CORRECTION
Community Reentry Center Screening Form
Appendix 1 (Fill-in Version)
322.02.01.002
(Appendix last updated 8/16/17)