Sex Offender Supervision Supplemental Monthly Report

Offender’s Name: IDOC Number:
PPO’s Name:
Offender’s Personal Information
ADDRESS:
HOME PHONE #:
CELL PHONE #:

List all those who live with you: (Names and ages):

EMPLOYER:
ADDRESS:

SUPERVISOR:
PHONE:

WAGE: $_______________
How many hours did you work this month? __________________
Did you miss more than one day at work? If so, why? ___________________________________________________

SCHOOL NAME:_______________________________________
Are you obtaining a GED or listing a major? _____________________________________________________
If pursuing a course of study what is your major? ________________________________________
# of credit hours:______________________________
Weekly schedule and number of hours in class: _______________________________________________________________________________________________________________________________________________________________

MEDICAL: List all medications you have taken in the past month (prescription and over the counter).
Medication Name: Dosing Instructions:


























Employer/School/Medical Information
Vehicle Information
Car #1
MAKE:

MODEL:

YEAR:


COLOR:
LICENSE#


Car #2
MAKE:

MODEL:

YEAR:

COLOR:
LICENSE#


Significant Other Information
NAME:
ADDRESS:
PHONE:

DATE OF BIRTH:
Has your PPO met significant other?
Yes  No 


Does he/she have children: Yes  No 
If yes, list gender and ages: ____________________________________________________________________________________________
Who do the children live with: _____________________ _____________________________________________
Name and phone # of other parent:
________________________________________________________________________________________________________________________________________________________________________________________________________


Chaperone Information

NAME:

PHONE:
DATE LAST
CERTIFIED:


NAME:

PHONE:
DATE LAST
CERTIFIED:


NAME:

PHONE:
DATE LAST
CERTIFIED:


This section must be filled out completely.
Date of your last registration with the sheriff’s office:
Date you last sent a quarterly verification to the sheriff’s office:
Date of your last polygraph:
COS/Restitution/Treatment Balance Information
COS BALANCE: $__________________
Amount of last payment: $_____________
Last payment date: __________________
RESTITUTION BALANCE: $___________
Amount of last payment: $_____________
Last payment date: __________________
SO TRT BALANCE: $________________
Amount of last payment: $_____________
Last payment date: __________________


Counseling/Programming/Substance Use/Law Enforcement Contact Information (Fill out all that applies to you)

Did you attend sex offender treatment this month? Yes  No 

If yes, you’re your sex offender treatment provider’s name?____________________
__________________________________

What areas are you currently working on in treatment? _________________________
__________________________________________________________________________________________________________________________________________________________________________

Have you missed any treatment this month? Yes  No 

If yes, have you made up the class?
Yes  No 

Explain any abnormal stressors you’ve had this month (if any): ___________________
__________________________________________________________________________________________________________________________________________________________________________

Did you attend substance abuse treatment this month? Yes  No 

If yes, you’re your substance abuse treatment provider’s name? ____________
__________________________________

What areas are you currently working on in treatment? _________________________
__________________________________________________________________________________________________________________________________________________________________________



Are you participating in any other groups or counseling (e.g., CSC, 12-step, peer support, AA/NA, individual counseling)? Yes  No 

If so, list them:

Group/counseling Date
_______________________ ______
_______________________ ______
_______________________ ______
_______________________ ______
_______________________ ______


Have you consumed alcohol since your last report? Yes  No 

Have you used controlled substances since your last report?
Yes  No 

If yes, what have you used? ___________
__________________________________________________________________________________________________________________________________________________________________________


Have you had any contact with law enforcement since your last report?
Yes  No 

If yes, please explain: ________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Do you have Internet access (either by wireless device, gaming stations, or computers)? Yes  No 

Community service or work program hours completed this month: # of hours completed: # of hours remaining:

I certify that the above information is correct and accurate as required by the court order. Also, I understand that providing false, misleading, or inaccurate information in this report
may result in a Report of Violation being submitted to my sentencing judge or the Commission of Pardons and Parole, and a warrant may be issued for my arrest or other disciplinary sanction

applied.

Offender’s Signature Date

You must attach a copy of your paystub, community service or work program hours, and any restitution or COS payments.