Sex Offender Supervision Activity Request

Offender Information
Name (Last)

(First)
IDOC#
Supervising PPO

Address
Phone

Crime of Conviction
Treatment Provider

Treatment Fee Balance
COS Balance
Child Support Balance
Restitution Balance


Polygraph History
Sentencing and/or Parole Date:
Full Disclosure
Date:
 Maintenance Date:
Last ComplianceDate:

Activity Information
Begin Date:
End Date:
Location Name, Address, and Phone #:

Chaperone:

Purpose of activities (or describe the activities):


Method of travel:

Who will be at the location?

Who will have knowledge of your crime?

Is there any potential your victim will be present?

Is there any potential for unplanned contact with minors?

Comments:


Treatment Provider’s Approval
Are the polygraph and fee balance information shown above correct?
Yes  No 
Is the Sex Offender Supervision Activity Request Safety Plan complete and appropriate?
Yes  No 
Is the chaperone appropriate for this activity?
Yes  No 
Has the offender missed appointments or assignments in the last 90 days?
Yes  No 

Other Comments:

Treatment Provider’s Signature:


IDOC Approval
Supervising PPO
Comments:_______________________________________________________________________
Classification level: ________________________
Approved  Denied 
District Manager (or designee)
Comments:___________________________________________________________________________________
Classification level: ________________________
Approved  Denied 

Supervising PPO’s Signature and Date:

District Manager‘s (or designee’s) Signature and Date: