Checklist Evaluating Pretrial House Arrest Applicant (To be completed by House Arrest Provider and submitted to the Gwinnett Sheriff’s Department.) Defendant: DOB: Inmate # Race: W Af.Amer. Hispanic Asian A Indian Sex [ ] Male [ ] Female The defendant is presently in pretrial custody at the Gwinnett Detention Center on the following charges. Offense(s) Warrant #, Accusation # Indictment # Probation/Parole Review [ ] The Defendant is NOT on probation or parole and have never been under either supervision. [ ] The Defendant is on probation/parole, or, in the event the Defendant has been on probation or parole, said supervising officer’s recommendation is as follows: (To be completed by House Arrest Provider) Probation/Parole Officer’s Name(s) Office Location Recommendation Concerning Suitability for House Arrest Program: Tel. # [ ] Approved [ ] Rejected [ ] Court’s discretion; Details: Probation/Parole Officer’s Name(s) Office Location Tel. # -1- Q:\Magforms\MAG 95-04 Checklist House Arrest Provider American LegalNet, Inc. www.FormsWorkflow.com Recommendation Concerning Suitability for House Arrest Program: [ ] Approved [ ] Rejected [ ] Court’s discretion; Details: Probation/Parole Officer’s Name(s) Office Location Tel. # Recommendation Concerning Suitability for House Arrest Program: [ ] Approved [ ] Rejected [ ] Court’s discretion; Details: Prosecutor Review Name(s) of Prosecutor Contacted Office Location Tel. # Recommendation Concerning Suitability for House Arrest Program: [ ] Approved [ ] Rejected [ ] Court’s discretion; Details: Name(s) of Prosecutor Contacted Office Location Tel. # Recommendation Concerning Suitability for House Arrest Program: [ ] Approved [ ] Rejected [ ] Court’s discretion; Details: Proposed Address Where Defendant Will Reside [ ] I have confirmed that the proposed living address submitted by the defendant as his/her place of residence is a private residence and is not a hotel, motel, boarding house or extended-stay facility: [ ] There is/will be a basic phone line at this location, # is:_________________________________________ [ ] The owner/lessor of the residence agrees to: [ ] keep this phone line available for electronic monitoring. [ ] not have any alcoholic beverages within the residence during the term of this order. [ ] permit a consent search of the entire premises, including vehicles on the premises, at any time of the day or night, during the time period the defendant resides at this residence. -2- Q:\Magforms\MAG 95-04 Checklist House Arrest Provider American LegalNet, Inc. www.FormsWorkflow.com Other Persons Residing at Residence Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Is there any reasons why the defendant should not be permitted to reside at this address? Proposed Employment [ ] I have confirmed the employment information submitted by the defendant and the following information is correct or is modified as follows: [ ] Employer’s Name [ ] Address [ ] Telephone # [ ] Supervisor’s Name [ ] Days to Work Conducting Alcohol & Drug Tests [ ] The Defendant has been incarcerated for MORE THAN THIRTY (30) DAYS and will not be required to submit to a drug test prior to admission into the program. [ ] The Defendant has been incarcerated for LESS THAN THIRTY (30) DAYS and has submitted to a drug test prior to admission into the program. The results of the test were negative. Date of test: ________________; Administered by: __________________________________________. Counties for Which Travel Should Be Permitted Other Than Gwinnett County Reason For Exception Barrow Cobb Dekalb -3- Q:\Magforms\MAG 95-04 Checklist House Arrest Provider American LegalNet, Inc. www.FormsWorkflow.com Fulton Forsyth Hall Walton Other Counseling, Treatment & Educational Programs For Which Permission to Attend Should be Granted AA NA Motor Vehicles Driving by the Defendant: [ ] Defendant should be permitted to drive provided he/she can show proof of a valid driver’s license, insurance and registration. [ ] Defendant should not be permitted to drive. [ ] Persons given permission to drive the defendant are: (No more than 4) Name of Driver Insurance Card Photocopied -4- Motor Vehicle Registration Current Q:\Magforms\MAG 95-04 Checklist House Arrest Provider American LegalNet, Inc. www.FormsWorkflow.com Drug Test [ ] Defendant PASSED drug screening test Date Administered: Person Administering test: [ ] Defendant FAILED drug screening test, testing positive for: Date Administered: Person Administering test: In my opinion, based on facts presently known, I hereby [ ] do recommend; [ ] do not recommend; consideration by the court of this defendant for placement in the Pretrial House Arrest Program. Date: Signature: Printed Name Telephone No: -5- Q:\Magforms\MAG 95-04 Checklist House Arrest Provider American LegalNet, Inc. www.FormsWorkflow.com