ZERO-TOLERANCE DRUG SUPERVISION PROGRAM APPLICATION, MOTION AND ORDER JD-CR-121 Rev. 3-2000 P.A. 98-145 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov INSTRUCTIONS Give Original to Clerk of Court and provide a copy to the Prosecutor. DOCKET NO. TO: The Judicial Authority of the State of Connecticut FROM (Name of Defendant) ADDRESS OF DEFENDANT JUDICIAL DISTRICT OR G.A. ADDRESS OF COURT CRIME(S) DEFENDANT CHARGED WITH OR CONVICTED OF DATE OF BIRTH NAME OF ATTORNEY (Include juris no.) APPLICATION I, the above-named Defendant, hereby make application for participation in the Zero-Tolerance Drug Supervision Program pursuant to the provisions of Public Act 99-187. I hereby make the following statements: 1. I am applying for participation in the zero-tolerance drug supervision program ("X" one) as a nonfinancial condition of release on bail by the court. on referral by my probation officer in lieu of a violation of probation proceeding. as a condition of probation ordered by the court pursuant to C.G.S. Sec, 53(a)-29. as a condition of probation ordered by the court as part of accelerated pretrial rehabilitation pursuant to C.G.S. Sec. 54-56e(d) as a condition of probation ordered by the court in a youthful offender proceeding pursuant to C.G.S. Sec. 54-76j(b). 2. At the time of the above noted offense(s) which I have been charged with or convicted of I was sixteen years of age or older. 3. I am not currently in any Zero-Tolerance Drug Program established pursuant to the Connecticut General Statutes. 4. I have not previously been in any Zero-Tolerance Drug Program established by the Connecticut General Statutes. 5. I do not currently require any medications or treatment for a physical, mental or medical condition, or, if I do require medication or treatment, I have attached a signed release to authorize the Court Support Services Division to communicate with my doctor or treatment provider to determine if detention pursuant to the Zero-Tolerance Drug Supervision Program would be detrimental to my health. 6. I am not on Methadone. 7. I have a history of drug use and I am not primarily a marijuana or alcohol abuser. I hereby agree and consent to the following if this application is granted: 1. To submit to periodic urinalysis drug tests. 2. To immediate detention in a halfway house facility for a period of forty eight (48) hours each time a periodic urinalysis drug test produces a positive result. 3. To comply with all rules established by the halfway house if I am detained in such a facility. 4. To waive the right to a hearing prior to being detained if a urinalysis drug test produces a positive result. I may request a second urinalysis test be administered, at my expense, to confirm the results of a positive first test, except that if I am determined to be indigent, the State shall pay for the second test. I shall be detained in a halfway house pending the results of the second test. 5. To begin the Zero-Tolerance Drug Supervision Program when instructed by the Court Support Services Division. 6. To remain in the Zero-Tolerance Drug Supervision Program for not less than six (6) months nor more than one (1) year, as determined by the Court Support Services Division. 7. To reside within the New Haven Judicial District, unless authorized to live elsewhere by the Court, throughout the period I am in the Zero-Tolerance Drug Supervision Program. 8. To comply with all of the terms and conditions of my probation or release. I, the above-named Defendant, declare under oath, that the foregoing statements are true, knowing that my false statement herein is punishable by law. SIGNED (Attorney for Defendant) DATE SIGNED SIGNED (Defendant) SIGNED (Parent/Guardian if minor) DATE SIGNED (continued) American LegalNet, Inc. www.FormsWorkflow.com FIRST ORDER OF COURT The foregoing application is denied. The case is continued until the date and time noted below to permit the Court Support Services Division to assess the applicant's eligibility. The defendant shall submit to urinalysis drug testing as directed by the Court Support Services Division and shall provide such medical, psychiatric or other waivers as requested by the Court Support Services Division to determine the defendant's suitability for the Program. The foregoing application is granted. [Use only if the Court Support Services Division completed assessment and the defendant signed the application.] CASE CONTINUED TO (Date and time) SIGNED (Judge, Assistant Clerk) DATE SIGNED COURT SUPPORT SERVICES DIVISION ASSESSMENT AND CONFIRMATION AT LEAST 16 AT TIME OF OFFENSE YES NO MEDICAL LIMITATION YES PRIOR PROGRAM PARTICIPATION NO YES NO ASSESSMENT ELIGIBLE INELIGIBLE OFFICER COMMENTS/EXPLANATION SIGNED (Officer) TITLE SECOND ORDER OF COURT (If continued for assessment) The foregoing application is denied. The foregoing application is granted. CASE CONTINUED TO (Date and time) SIGNED (Judge, Assistant Clerk) DATE SIGNED JD-CR-121 Rev. 3-2000 (Back/Page 2) (Page 2 of 2) American LegalNet, Inc. www.FormsWorkflow.com