Screening Form for Sexual Violence - The National PREA Resource ...

STATE OF CALIFORNIASEXUALLY VIOLENT PREDATOR SCREENINGCDCR 7377 (REV. 03/08)INMATE NAME (LAST, FIRST, MI) CDC NUMBER SCREENING LOCATIONDEPARTMENT OF CORRECTIONS AND REHABILITATIONPAROLE USE ONLYPENDING REVOCATION? PAROLE HOLD DATENO YESCI&I NUMBER COUNTY(IES) OF PRESENT COMMITMENT DISCHARGE/ARCHIVE NUMBER(S) EPRD PRRD RRD CDDWELFARE AND INSTITUTIONS CODE SECTION 6600 QUALIFYING OFFENSESPC 261 Rape-(all subdivisions)NOTE: Include all defined “Rape by Threat” convictions.PC 262 -Rape of Spouse (all subdivisions)PC 264.1 – In concert w/ another to commit PC 261, PC 262, or PC 289.PC 269 – Aggravated Sexual Assault of Child (all subdivisions)PC 286 – Sodomy (all subdivisions).PC 288 – Lewd or Lascivious Acts with a child (all subdivisions)PC 288.5 – Continuous Sexual Abuse of Child Under 14. (all subdivisions)PC 288a – Oral Copulation (all subdivisions).PC 289 – Sexual Penetration (all subdivisions)(MARK ONE BOX ONLY)NO:YES:MAYBE:Felony conviction of PC 207, PC 209, or PC 220, committed with the intent to commit aviolation of 261, 262, 264.1, 286, 288, 288a or 289Include all:! Convictions resulting in a MDSO finding.! Not guilty by reason of insanity findings that involve a qualifying offense.! Qualifying convictions dismissed or expunged pursuant to PC 1203.4.! Juvenile offense occurred at age 16 or older resulting in State confinement.! Sentence of adult probation.NOTE: Refer to instructions for additional information.INSTITUTION/PAROLE SCREENING DETERMINATION OF SOCIAL AND CRIMINAL HISTORYSubject has no qualifying convictions. PC 290 registrant due to:Meets criteria as a potential SVP pursuant to Welfare and Institutions Code Section 6600 and all required documentation,including archive material are included in the packet.A conclusive determination cannot be made based upon a review of the Central file and Archive file documents.(Note and attach information on sex related RVRs, psychiatric reports, CDC Form 128C/B, etc.)Comments/additional information needed:YES or INTERPRETER NEEDED? NO YES Language: MENTAL HEALTH STATUSMAYBESelect: N/A, CCCMS,ONLY DPP/DDP? NO YES Disability:EOP, MHCB, or DMHC O N V I C T E D QU AL I F Y I N GPCOFFENSE(S) ONLYPC PC PCDATE OF OFFENSEDATE OF CONVICTIONCOUNTY OR STATE OF CONVICTIONSUPERIOR COURT CASE NUMBERNUMBER OF CONVICTED COUNTSNUMBER OF STAYED COUNTSNUMBER OF VICTIMS ANDRELATIONSHIP TO THE OFFENDER / / / /Documents REVIEWED for SVP screening:LSS ISRS POR AOJ FBICOMPL/INFO CI&I ARCHIVEOTHER:Documents ATTACHED (sent to Classification Services):CDC1884 CDC112 LSS ISRS PORs a m p l eAOJ COMPL/INFO CI&I FBIARCHIVEOTHER:In order to make an accurate SVP determination, I have completed a thorough review of all central file documentationCorrectional Counselor/Parole Agent (Print Name)I concur with the screening determination.C&PR/CCIII/PAIII (Signature)CLASSIFICATION SERVICES UNIT USE ONLYFor all RTC “YES” cases include:Parole Violation Charge SheetSummary of Revocation DecisionDate of ReviewDate SignedREVIEWER INITIALS DATE RECEIVED AT CSU DATE ADDED TO DATABASE 290 LIST DATE / INSTITUTION MANUAL ADD LIST DATECSU RESULT: NO / YES / MAYBE Per: ________ Agree / Disagree with Screener (See Comments)Comments:Distribution: Original - Central File, Legal SectionCanary - Classification Services Unit (CSU)Pink - Inmate (Upon Request)

STATE OF CALIFORNIASEXUALLY VIOLENT PREDATOR SCREENINGCDCR 7377 (REV. 03/08)INSTRUCTIONSDEPARTMENT OF CORRECTIONS AND REHABILITATIONINMATE NAME AND CDC NUMBER - Obtain from the Legal Status Summary (LSS).SCREENING LOCATION - Indicate where the SVP case was screened (e.g., Institution, Parole Region/Unit, or County Jail).PAROLE USE ONLY - Concerns Pending Revocation (PEND REV) cases. Indicate the date of the parole hold.CRIMINAL IDENTIFICATION AND INFORMATION (CI&I) NUMBER - Obtain from the CI&I (California Law Enforcement Teletype System-CLETS) printout, the Probation Officer's Report (POR) or from the COFQ query in the Offender Based Information System (OBIS).COUNTIES OF PRESENT COMMITMENT - Obtain from the LSS or the Abstracts of Judgment (AOJ). If there are multiple, list all.DISCHARGE/ARCHIVE NUMBER(S) - Obtain from the POR, CI&I, COFQ/OBIS. Request file if additional information is needed.RELEASE DATES - Obtain release date information from the CDC Form 112, Chronological Inmate History. Include all dates that areavailable, and if necessary, include “estimated” dates. If release date is estimated, note, i.e. 12/21/08 (EST). Parole regions are alsoresponsible for including any available release date information.QUALIFYING OFFENSES - Review AOJ, POR, CI&I (CLETS), Multistate and FBI rap sheets for felony convictions for a WIC Section 6600qualifying offense. Include Mentally Disordered Sex Offender (MDSO) convictions/findings and specific Not Guilty By Reason of Insanityfindings associated with a qualifying offense. Include all qualifying convictions that were dismissed, expunged or absolved via a "Certificate ofRehabilitation" pursuant to PC Section 1203.4. Include all Juvenile convictions wherein the offender was convicted as an adult. Include nomore than one Juvenile conviction when the SVP qualifying offense occurred at age 16 or older and resulted in State confinement (e.g., CYA #or M# on CI&I) and sentences of Adult Probation. Do not include: 1) Juvenile sustained petitions: determinations that resulted in placementother than a State Facility such as: Juvenile Hall, County Ranch/Camp or Home Placement, or 2) Attempts and assaults to commit SVPqualifying offenses (i.e. PC 664/220 or Attempted Rape).SCREENER'S DETERMINATION - Mark one determination only. This is the Institution or Parole SVP case determination. Institutions/Paroleare responsible for all final "NO" case determinations.NO -- Designate when no qualifying WIC Section 6600 felony conviction exists. Indicate what offense requires registration pursuant to PC290 and list the year of conviction, i.e. “314.1 (2003)”YES -- Designate when the case meets potential SVP criteria, (e.g., offense(s) + victim(s) + relationship) and all required documentation,including archive material, is available and contained in the packet. Include any additional pertinent information (e.g., CDC Form 128B,Information Chronos; CDC Form 128C, Medical-Psychiatric Chronos; CDC Form 115, Rules Violation Reports with sex related/bizarre behaviorreported; etc.) which enhance the case.MAYBE -- Designate when Central file and Archive file documentation cannot support a conclusive determination (YES or NO) and additionalinformation is needed to determine: arrest disposition(s), out of state/federal/military sex offense convictions, court follow-up, etc. Indicate inthe “Comments” section what information or documentation is needed in order to make a definitive determination.INTERPRETER NEEDED, DPP/DDP, or MENTAL HEALTH APPLICABLE – YES and MAYBE cases only. In the event of a scheduledclinical evaluation by the DMH, indicate if an interpreter is needed and the specific spoken language. Also list any disability and mental healthstatus issues, if applicable.CONVICTED QUALIFYING WIC SECTION 6600 OFFENSE(S) ONLY -Do not complete this section for "NO" case determinations.DATE OF OFFENSE - Date the offense(s) occurred. Obtain the date(s) from the AOJ, LSS, POR, Complaint/Information, FBI or Multistate.DATE OF CONVICTION - Date of conviction for the qualifying offense(s). Obtain from the AOJ, LSS, POR, CI&I, FBI or Multistate.COUNTY OR STATE OF CONVICTION - Where the conviction occurred. Obtain from the POR, CI&I, FBI or Multistate.SUPERIOR COURT CASE NUMBER - For the qualifying offense(s). Obtain from AOJ, LSS, POR, CI&I, FBI or Multistate.NUMBER OF CONVICTED COUNTS - For any specified offense(s). Obtain from the AOJ, LSS, POR, CI&I, FBI or Multistate.NUMBER OF STAYED COUNTS - For any specified offense(s). Not reflected on the LSS. Obtain from the AOJ or POR.NUMBER OF VICTIMS AND THEIR RELATIONSHIP - Only include victims identified in convicted counts. Be cautious of cases involvingmultiple counts for the same victim. Indicate the victim’s relationship to the offender.DOCUMENTS REVIEWED FOR SVP SCREENING - Checkmark the boxes of documents reviewed to substantiate the determination. If adocument is not available, place n/a in the box.DOCUMENTS ATTACHED – For “YES” and “MAYBE” cases only, checkmark the boxes of documents which will be included in the packet(s).Send a copy of each of the supporting documents, attached to the CDCR 7377, to CSU.FOR ALL RETURN TO CUSTODY CASES (RTC) RECYCLE/YES CASES - Attach the CDC Form 1676, Charge Sheet/RevocationTracking/Scheduling Request and the Board of Parole Hearings Form 1103, Summary of Revocation Hearing and Decision.ORIGINATOR OF THIS FORM – Print the name of the screener and indicate the date of review.C&PR/CCIII OR PAROLE AGENT III SIGNATURE - By signing and dating this form, the C&PR/CCIII/PAIII attests to its completeness andaccuracy.NOTE:s a m p l eA case reviewed and determined by the institution to be a "NO" only requires the submission of the NEW SVP screening form. The originalcopy of the SVP screening form shall be placed on the drop board under the fingerprint card in the Legal section of the central file. A copy ofthe SVP form, along with pertinent documents for "YES" and "MAYBE" cases shall be forwarded to CSU for review.Mail a Copy with the supporting documents (if applicable) to:California Department of Corrections and RehabilitationInstitutions Division, Classification Services Unit1515 S Street, Room 300 NSacramento, CA 94283-0001Attn: SVP SectionDistribution: Original - Central File, Legal SectionCanary - Classification Services Unit (CSU)Pink - Inmate (Upon Request)