Release Questionnaire Please enable JavaScript in your browser to complete this form.1) Name of Individual *FirstLastIndividual's Date of Birth *3) Inmate's Release Date *4) Facility from which the individual will be released. *Barstable County Correctional FaciltyBerkshire County Jail and HOCBoston Pre-Release CenterBridgewater State HospitalBristol County HOC and JailDukesCounty Jail and HOCEssex County Correctional FacilityFranklin County Jail and HOCHampden County Jail and HOCHampshire County Jail and HOCLemuel Shattuck Hospital Correctional UnitMASAC at PlymouthMassachusetts Treatment CenterMCI-Cedar JunctionMCI-ConcordMCI-FraminghamMCI-NorfolkMCI-ShirleyMiddlesex Jail and HOCNantucket County JailNashua Street JailNorfolk County Correctional CenterNorth Central Correctional InstitutionNortheastern Correctional CenterOld Colony Correctional CenterPlymouth County Correctional FaciltyPondville Correctional CenterSouth Bay HOCSouza-Baranowski Correctional CenterWorcester County Jail and HOCOther5) Who will transport the individual from the releasing facility? *6) Is the individual on probation or parole? *ProbationParoleNeither7) Court of Jurisdiction *8) Does the individual have a GPS requirement? *YesNo9) Has the individual have a level of designation by the Sex Offender Registration Board (SORB)? *YesNo (skip Question 10)10) What is the SORB level?Level 0Level 1Level 2Level 311) Is the individual fluent in English? *Yes (skip Question 12)No12) If not English, what is their primary language?ChineseSpanishArabicFrenchPersianGermanRussianMalayPortugueseItalianTurkishLahndaTamilUrduKoreanHindiBengaliJapaneseVietnameseTeluguMarathiOther13) Does the individual have health issues (non-mental)? Please describe: *14) Does the individual have mental health issues? Please describe: *15) Does the individual have mobility issues? Please describe: *16) Does the individual require medication? *Yes (answer 16a, 16b, and 16c)No (go to Question 17)If the inmate requires medication but will not be provided medication, they must be provided prescription(s) for the medication.16a) Please list all required medications.16b) Will the individual be released with a supply of medication?YesNoNot sure16c) If the individual is diabetic, will they be provided:InsulinNeedlesA blood sugar test kit with test stripsn/a17) Has the individual's Standard (not Basic) MassHealth coverage been activated? *YesNoUnknown18) Does the individual have a military affiliation? *NoYes (they have their DD-214 form)Yes (they do NOT have their DD-214 form)Unknown19) Does the individual have their birth certificate? *YesNoUnknown20) Does the individual have a social security card? *YesNoUnknown21) Does the individual have a valid Massachusetts ID? *YesNoUnknown22) Does the individual have property in the Property Department to be acquired upon release? *YesNon/a23) Has housing been secured for the individual? *NoYes (no time restriction)Yes (there is a restriction on the amount of time at this housing?24) Emergency Contact Name25) Emergency Contact Phone NumberName of party responsible for completing questionnaire. *FirstLastOrganization submitting questionnaire. *Submit
