PRE-DISPOSITIONAL/PRE-PLEA/PRE-SENTENCE INVESTIGATION REPORT WORKSHEET

County

Docket/ Indictment Number

Court

Investigation Case Number*

Date Investigation Ordered

Agency Code (ORI) *

NY
G

Name* (Last)

(First)*

Investigating Probation Officer

Date Report Completed

A. PERSONAL INFORMATION
(M.I.)

(Maiden Name)

Alias/Nickname

Present Address*

Telephone Number

DOB*

Age

Place of Birth

Ethnic Origin*

Race*

Height

Weight/Lbs.

Citizenship

Eyes

Hair

ICE Status

Marital Status **

Sex*

Total in Home

Male
Social Security Number

Identification Marks

Employment/School Status *

Female

Education

Military Service

Employer/School *

Annual Income
$

B. PRESENT COURT PROCEEDINGS

Judge

Prosecuting Attorney

Counsels Name and Address

Offense Date

Arrest Date

Information/Indictment/Petition Numbers

Information/Indictment/ Petition Date

Information/Indictment Charges/Nature of Petition

Conviction/Adjudication Date *

Conviction Charge Code * (Criminal Court Only)

Final Conviction/Adjudication Charge

By Plea/Admission
By Verdict/Finding
C. LEGAL INFORMATION
NYSID Number *

Court Control Number/CJTN *

Status of Defendant/Respondent on Date of

Interview by Probation Officer

Bail

ROR

Detention

Detention Date
Scheduled Sentence/
Disposition Date

Local Identification Number

FBI Number

Sentence/Disposition *
Designated Felon
DIR Filed
YES
DNA Collection Required
Fingerprintable Offense
Juvenile Offender
SORA Registerable Case
Youthful Offender
Eligible

YES
NO
NO
N/A
YES
NO
YES
NO
YES
NO
YES
NO
Required
N/A

Sentence/Disposition Date *

Certificate of Relief from Disabilities by Court

Eligible

YES

NO

N/A

Recommended

YES

NO

DEFER

DRUGS USED AT OFFENSE

YES

NO

UNKNOWN

CONFLICTING INFORMATION

BLOOD ALCOHOL CONTENT ***

ALCOHOL USED AT OFFENSE

YES

NO

UNKNOWN

CONFLICTING INFORMATION

BAC Test Refused ***

OTHER PENDING CHARGES

PRIOR COURT CONVICTIONS/
ADJUDICATIONS

YES

NO

YES

NO

IF YES, ENTER NUMBER AND

REFER TO THE LEGAL HISTORY
FOR VERIFICATION

PRIOR DWI/DWAI
CONVICTIONS

YES

NO

IF YES, ENTER NUMBER AND

REFER TO THE LEGAL HISTORY
FOR VERIFICATION

*Required for Integrated Probation Registrant System (IPRS)

DPCA-221 (6/06)

Personal Injury or
Fatality
INJURY

YES

NO
FATALITY

NO

UNKNOWN

If Driving Offense: Drivers License #

** Required for ISP Cases

***Required for DWI/DWAI Cases

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D. CO-DEFENDANTS/CO-RESPONDENTS
Name

Age

Address

Status

NYSID No. (If Available)

E. PARENTS AND/OR SPOUSE (INCLUDE STEP FAMILY)

Name

Relation

Age

Address

Occupation/Job Position

F. SIBLINGS AND/OR CHILDREN (INCLUDE STEP FAMILY)

Name

Relation

Age

Address

Occupation/Job Position

G. VERIFICATION
Check if
Verified

Check if
documented
in file

Method

Source

By Whom

Date

Date of Birth
Citizenship
Legal History
Present Offense/Conviction
Current Address
Employment and Salary
Mental Health
Physical Health
Treatment Provider
Treatment Provider
Education/Training
Victims Damages/Losses
Military
Other
Other

H. PROFESSIONAL LICENSES
Type

License Number

Granted By

I. FIREARMS LICENSES
Type

DPCA-221 (6/06)

License Number

Granted By

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J. RESIDENCE HISTORY
From

With (Name/Relationship)

Current Address
Past Residences

From

To

With (Name/Relationship)

Reason for Leaving

PO Remarks

K. EDUCATION
School(s) Attended

From

To

From

To

Reason for Leaving

PO Remarks

L. EMPLOYMENT
Employer (Name/Address)

Occupation

Wages/Wk.

Reason for Leaving

PO Remarks

M. SKILLS AND INTERESTS

Skills, Trainings, Certifications, Interests, Hobbies, Volunteer Work

PO Remarks

DPCA-221 (6/06)

Page 3 of 6

N. OTHER SOURCES OF INCOME

Public Assistance
$
Stocks
$
PO Remarks

Medicaid
Yes
No
Bonds
$

Disability Benefits
$
Retirement
$

Social Security
$
Unemployment Insurance
$

SS Disability
$
Child Support
$

O. MILITARY
Years of Military Service
ENTRY
Discharge Type

Branch

Service Number

Rank

DISCHARGE
Reason

PO Remarks

P. PHYSICAL AND MENTAL HEALTH

Medical Doctor (Name and Address)

Current Medical Problems

Hospitalization(s) (Name, Location and Date)

Significant Past Illnesses/Injuries

If Treated by Psychiatrist/Psychologist (Name, Address and Dates)

Required Medications

PO Remarks

Q. HISTORY OF SUBSTANCE ABUSE INVOLVEMENT

HISTORY
TYPE

EVER
USED
(X if Yes)

CURRENT
AGE

FIRST
USE

LAST
USE

FREQ. OF USE

CURRENT
USE
(X IF YES)

AMOUNT
USED

FREQ.OF USE

FREQUENCY
WEEKLY
COST

SOURCE
OF INFOR.

ALCOHOL

A B C D

A B C D

1 2 3 4 5

MARIJUANA

A B C D

A B C D

1 2 3 4 5

COCAINE/CRACK
HEROINE/
MORPHINE
METHADONE

A B C D

A B C D

1 2 3 4 5

A B C D

A B C D

1 2 3 4 5

A B C D

A B C D

1 2 3 4 5

AMPHETAMINES

A B C D

A B C D

1 2 3 4 5

BARBITURATES

A B C D

A B C D

1 2 3 4 5

PCP

A B C D

A B C D

1 2 3 4 5

OTHER

A B C D

A B C D

1 2 3 4 5

OTHER

A B C D

A B C D

1 2 3 4 5

NUMBER OF ALCOHOL RELATED ARRESTS

NUMBER OF DRUG RELATED ARRESTS

A) 4 OR MORE
DAYS/WEEK
B) 1 3 DAYS/WEEK
C) 1 TO 3 DAYS/
MONTH
D) LESS THAN 1
DAYS/MONTH
SOURCE
1) TESTING
2) SELF ADMISSION
3) THIRD PARTY
INFORMATION
4) PHYSICAL SIGNS/
SYMPTOMS
5) OTHER

R. HISTORY OF TREATMENT
Program Type
Dates (Length of Treatment)

DPCA-221 (6/06)

Program (Name and Address)

D = Detox
R = Residential
O = Outpatient
Y = Day Treatment

PO Remarks

Examples:
- Never Treated
- Types of Substances Treated For
- Successful Completion

Page 4 of 6

S. PRESENT OFFENSE/ACT
DEFENDANTS/RESPONDENTS DESCRIPTION: Reasons for committing, perception of consequences, expressed future behavior, relationships
with victim and co-defendant/co-respondent, aggravating or mitigating circumstances, ability to
make restitution, etc.

VEHICLE INFORMATION:

DPCA-221 (6/06)

Page 5 of 6

T. VICTIM(S)
Name and Address

Current
Age
Age at
Offense

Date

Time

Place/Address

Type(s) of Weapons

Injuries

Damage to Property
Financial Loss(es)

Victim/Offender Relationship

Restitution/Reparation Sought by Victim

Victims Version of Offense

Date Victim Impact Statement (VIS) Sent

Date Victim Impact Statement (VIS) Received

PO Remarks

U. ADDITIONAL INTERVIEW OBSERVATIONS

PO Observations/Remarks

DPCA-221 (6/06)

Page 6 of 6