THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) DETENTION ASSESSMENT SCREENING INSTRUMENT Date Screened / Time: I. IDENTIFYING DATA Last Number and Street/City/State/Zip Gender Race First MI DOB Telephone Number Ethnicity Student at: (Name of school and address) Employed by: (Name of company and address) Parent / Guardian Number and Street/City/State/Zip Telephone Number(s) Non-Custodial Parent Number and Street/City/State/Zip Telephone Number(s) Alleged Present Offense(s) (Specify level and class / Felony, Misdemeanor A, B, etc.) N/A Regarding the juvenile, did the arresting / investigating officer observe evidence of: alcohol abuse? Yes No drug abuse? Yes No Did the arresting officer note any signs or symptoms of suicidal ideations or actions? Yes No Parent / Guardian Interviewed 1. Face to Face 3. Unable to Contact Yes No 2. Telephone 4. Message Left With Whom: Name Relationship Law Enforcement Agency Officer's Name and ID or Badge No. (officer who completes this form) (JPPO) NHJB-2581-DF (03/09/2009) District Office Contacted? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: DETENTION ASSESSMENT SCREENING INSTRUMENT Prior Juvenile Convictions or Diversion Specify (Court or Law Enforcement Agency) Yes No Juvenile Contacts (Counseled & released) Specify (Court or Law Enforcement Agency) Yes No Juvenile Record Check: II. ADMISSION CRITERIA Yes Not Available No Priors If answered in the affirmative, the following criteria indicate the youth's potential eligibility for detention. Yes No 1. The youth is alleged to be an escapee from jail, youth attendant program, shelter care, detention unit, an absconder from a residential program, or the youth is wanted in another jurisdiction for an offense, which if committed by an adult, would be a felony; 2. The youth has been charged with a delinquent act or violation of law and requests in writing through legal counsel to be detained for protection from an imminent physical threat to his/her personal safety (attach documentation); 3. The youth is charged with a capital crime, a Class A Felony, a Class B Felony or Felony violation under chapter 318-B; 4. The youth is charged with a Class A Misdemeanor or any offense involving the use of firearm and if one of the factors set forth below exists: No (a) youth has a record of failure to appear at court hearings after being properly notified in accordance with the rules of juvenile procedure; (b) youth has a record of law violations prior to court hearings; (c) youth has already been detained or has been released and is awaiting final disposition of his case; or (d) youth has a record of violent conduct resulting in physical injury to others; (e) youth found to be in possession of a firearm or other deadly weapon; (f) present offense involves a domestic violence charge. Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes No No No No No If any of the above (1-4) are answered Yes, proceed to Section III. If each of the above (1-4) is answered No, the youth should not be detained. NHJB-2581-DF (03/09/2009) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: DETENTION ASSESSMENT SCREENING INSTRUMENT III. A youth delivered with a judicial order requiring detention must be detained. The screening instrument still must be completed for informational purposes, but the youth must be detained regardless of the point score. ***** RISK ASSESSMENT (indicate charge used for calculation) A. Most serious current offense. (Count only most serious, do not add charges together) (Max) 1. Capital, first degree, second degree homicides and manslaughter: or 15 2. Level IV offenses under Detention/Dispositional Offense Rankings 15 or youth is wanted by another jurisdiction for a felony offense; or 3. Level III offenses under Offense Rankings; or 8 4. Level II offenses under Offense Rankings and 4 any misdemeanors charged as Class A B. Other pending charges (separate, non-related events occurring prior to instant offense). Pending charges are charges on which a juvenile is awaiting an adjudicatory or dispositional hearing. 1. Prior felony arrest within last seven days 6 2. Each felony - 2 points (if not included in #1) total 3. Each Class A misdemeanor - 1 point total C. Legal Status (Open Delinquency Cases Only) 1. Presently committed or detained by prior Court Order 8 2. Active case with last adjudication/disposition or adjudication 6 continued within 90 days whether on conditional release or not 3. Active case with last adjudication/disposition or adjudication 2 continued more than 90 days ago whether on conditional release or not D. Prior History (Closed Delinquency Cases Only) 1. 3 adjudications/dispositions or 3 adjudications continued for felony 9 level offenses in last twelve months, or 2. 2 adjudications/dispositions or 2 adjudications continued for felony 5 level offenses in last twelve months, or 3. 1 adjudication/disposition for felony level offense or adjudication 2 continued or 2 Class A misdemeanor adjudications/ dispositions or adjudications continued in the last twelve months, or 4. 3 or more adjudications/dispositions for Class A misdemeanor 3 offenses or 3 or more adjudications continued for Class A misdemeanor offenses in last 12 months E. Aggravating/Mitigating Factors 1. Aggravating factors (add to score) specify: 0-3 (example: presently in shelter care) 2. Mitigating factors (subtract from score) specify: (example: domestic assault involved mutual combat) minus (0-3) Fully explain the reasons for scoring aggravating or mitigating points NHJB-2581-DF (03/09/2009) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: DETENTION ASSESSMENT SCREENING INSTRUMENT F. Detain/release decision Total (Sum A-E) 0 - 6 points = release 7 -11 points = eligible for shelter care, house arrest, electronic monitoring, day center, or other alternatives 12+ points = eligible for secure detention Yes No Home (Judge) 0 IV. SCREENING DECISION Eligible for detention?: Placement?: Secure Non-secure Release (Court) If JPPO recommended override - state reason(s): If Judicial override - state reasons(s): Released to: Name: Address: Telephone: Parent/Guardian refused to take youth home? Notification of Detention Hearing - Date: Time: Yes No Time: Signature of official completing form Date Signature of person who reviewed assessment (if applicable) Date V. ADDITIONAL INFORMATION FOR THE SYSC ­ DETENT