Release Questionnaire

1) Name of Individual *

First

Last

2) Individual's Date of Birth *

3) Inmate's Release Date *

4) Facility from which the individual will be released. *

5) Who will transport the individual from the releasing facility? *

6) Is the individual on probation or parole? *

Probation
Parole (BRN cannot accept a parolee without permission)
Neither

7) Court of Jurisdiction to report for probation *

8) Does the individual have a GPS requirement? *

Yes
No

9) Has the individual have a level of designation by the Sex Offender Registration Board (SORB)? *

Yes
No (skip Question 10)

10) What is the SORB level?

Level 0
Level 1
Level 2
Level 3

11) Does the individual have health issues (non-mental)? Please describe: *

12) Does the individual have mental health issues? Please describe: *

13) Does the individual have mobility issues? Please describe: *

14) Does the individual require medication? *

Yes (answer 14a, 14b, and 14c)
No (go to Question 15)

If the inmate requires medication but will not be provided medication, they must be provided prescription(s) for the medication.

14a) Please list all required medications.

14b) Will the individual be released with a supply of medication?

Yes
No
Not sure

14c) If the individual is diabetic, will they be provided:

Insulin
Needles
A blood sugar test kit with test strips
n/a

15) Has the individual's Standard (not Basic) MassHealth coverage been activated? *

Yes
No
Unknown

16) Does the individual have a military affiliation? *

No
Yes (they have their DD-214 form)
Yes (they do NOT have their DD-214 form)
Unknown

17) Does the individual have their birth certificate? *

Yes
No
Unknown

18) Does the individual have a social security card? *

Yes
No
Unknown

19) Does the individual have a valid Massachusetts ID? *

Yes
No
Unknown

20) Does the individual have property in the Property Department to be acquired upon release? *

Yes
No
n/a

21) Has housing in Massachusetts been secured for the individual? *

Yes (go to 21a and skip 21b)
No (go to 21b and skip 21a)

21a) Massachusetts housing address, phone #, and contact name.

21b) What travel arrangements (bus, train, plane, etc.) have been secured for the individual. Please give details.

22) Emergency Contact Name

22) Emergency Contact Phone Number

Name of party responsible for completing questionnaire. *

First

Last

Email address for party completing questionnaire. *

Organization submitting questionnaire. *

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