of Numan S.rvtc:• • DUI Service Reporting System (eDSRS ... · 2 $16,910 3 $21 330 4 $25 750 5 $30,170 6 $34.590 7 $39.010 8 $43.430 For each additional oerson add $4.420 The

lllanoia Departme nt of Numan S.rvtc:• •

DUI Service Reporting System (eDSRS)

User Reference Manual

*

Last Update: 01 July 2018

Table of Contents SECTION 1 - INTRODUCTION ........................................... ~·············· ............................................ <ll l ll• ......................................... 1 SECTION 2 - GENERAL SYSTEM INFORMATION .............................................................................................. 3

System Requirements ................ ........... ......... ........... ...... ............... ........ ..... ...... ..... ... ................................... 3 System Security ........ .................. .......... ...... .. .......................... .............. .... .. .... ............................................ 3 Worker Registration and Security Roles ..... ..................... .......... .............. .... ............. .................................. ... 3 Change Password and Request User ID Change ...... ....... .. ........ .................. .. ....................... ......................... 4 Credential Updates ..... .............................. ..... .............. .. .. .... .. .... ...................... ...... ....... .... .. ..................... .... 5 Login ............... .. .. .... .............. .......... ........ ..... ............. ........ .. ......... ....... ....... ..... .... ....... ..... .. ........... .............. 5 Worker Home Page .... .......... .......................... ..... ...... ......... .................... ... ............... ........ .. ......................... 6 Unlocking A Completed Evaluation or Risk Education ........ .......... .................................... .. ............................. 6

SECTION 3 - OFFENDER INFORMATION .................................. ............................................................... M.,,.111, • • ••••••••••••••••• 7 3.1 OFFENDER SEARCH .. ........ ..................... ........ ... ........ .... .. .......... ........ .. .............................. .. ..... .............. ..... 7 3.2 DUI OFFENDER INFORMATION ............. .......... ........ ............. .. ... ..... ............. .............. .... ............................... 9 3.3 OFFENDER DEMOGRAPHICS .................. ....... ........... ........ ......... ......... ...... ............ ..... ...... .. .. ....................... 10 3.4 OFFENDER SUMMARY .. ..................... ..................... ................ .. ...... ...... ............. ..................... ................... 11

SECTION 4- EVALUATION INFORMATION .................. ................................................... ............................... 12 4.1 CURRENT ARREST INFORMATION .... ............ ... ............ ... ....... ..................... ...... ......................................... 13 4.2 ALCOHOL and DRUG RELATED LEGAL & DRIVING HISTORY ................................ .................. ... ... .......... ...... 14 4.3 SIGNIFICANT ALCOHOL/DRUG USE HISTORY ..... .... ........... ............ .......... .... ......... ......... .. .......... ................. 16 4.4 OBJECTIVE TEST INFORMATION ................... ..... ....................... ........ ............... ......... ......... ............. ..... ..... 19 4.5 CRITERIA FOR SUBSTANCE USE DISORDER ...................................... .... ............................... ...................... 19 4.6 OFFENDER BEHAVIOR ................ .... ... ............. ................ ................. ...... ......... ......... ..... ..... ..... ........ ........... 20 4.7 CLASSIFICATION/ MINIMAL REQUIRED INTERVENTION ......... ............ .... ............... ...... ... ..... .. ................. ... . 21 4.8 EVALUATION DISPOSITION ..... ............. ..... ..... .............. ...................... ............ ...... ...... .. .. ... ..... ....... ........ .... 22

SECTION 5- RISK EDUCATION INFORMATION .... ....... ... .............................................................................. . 24 5.1 RISK EDUCATION .......... ... .............. ..... .... ...... .................................. .............. ...... .... ..... ....... ................. ... . 24 5.2 RISK EDUCATION DISPOSITION .................. ............................................................... ....... ..... ............... .... 25

SECTION 6 - PROVIDER INFORMATION ........................................................................................................ 26 6.1 PROVIDER INFORMATION ........ ................. ........................ ........... .... .. ... ..... ........................................ ....... 26 6.2 SITE INFORMATION ........... ... .... .... ........... .. ......... ... .......... ....... ... .................. ............................... .. ............ 28 6.3 EVALUATOR INFORMATION .... ......... ... ............................... ........... ............ .. ......... ...................... ...... ... .. .... 29

SECTION 7 - DDDPF BILLING/VOUCHERS ...................... ....................... ... ... ......... ..... ... .. .... ..... ...................... 32 7. 1 DDDPF BILLING APPROVAL .......................... ..... .......... ........................... ........ ..... .... ....... .... .. ... ....... ....... .... 32 7.2 DDDPF SUBMITTED VOUCHERS ... ............... .................. ...... .............. ...... .............. .... .... ........ ......... ......... ... 33

SECTION 8 - REPORTS ................................................................................................................................... 34 SECTION 9 - RESOURCES ............ ~ .................................................................................................................... 3S

APPENDIX A- DHS FORMS .................................................................................. ..................... , .................... , 36 IL 444-2030 ..... ....... ....... ..... ....................... ... ..... ............... ................... ................................................. ................ 37 IL 444-2031 ... ......... ..... ..... ......... ............... ......... .......................... .................. .................. ....... .............................. 49 IL 444-2032 ............. .... .............................. .................... ........... ........................................................................... . 50 IL 444-2033 ..... ............. .................. .............. .... .. ................................ ....... ................ ..... ... .............. .......... ........... 51 IL 444-2034 ...... .......... ...... ........... ........................ .. ........ ...... .......... .......... ....... ..... .. .... ........ .................. ............... .. 52

APPENDIX B - SAMPLE REPORTS ................................................................................................................... 53 EVALUATION STATISTICS .................. ................................. ....... .... .......... ................. ..... ....................... .. ... ........... 54 EVALUATION SERVICES ...... ............ .. ....... .... .. .............. ... ...................... ... ............ .. ... ............................................ 54 RISK EDUCATION STATISTICS .. .. ... ..... ... ....... ...................... .................. ......... ...... ........ ..... ............... ................... .. 5S RISK EDUCATION SERVICES ..... .................... .... .... ................ .... ................... ............... ................... ....... ....... ......... 55 EVALUATOR/ EDUCATOR INFORMATION ......... ....... .. ... ........................ .... ....................... ............................... ......... 56 DDDPF BILLING ..... .. ............... ..................... .............. ...... ........... .. .............................. ..... ...... .. ........ ........... ......... . 56 PROVIDER WORKER LIST .......... .......................... ........ ..... ..... ....... ... .... ....... .............................. .... ..... .......... ... ... ... . 56

eDSRS User Reference Manual I I

SECTION 1 ~ INTRODUCTION

The Unified Health Systems DUI Service Reporting System (eDSRS) application is designed to generate the Alcohol and Drug Evaluation Uniform Report and other forms and reports associated with a DUI Evaluation or DUI Risk Education program for individuals who have violated Illinois laws relative to driving under the influence of alcohol or other drugs. It also submits bills for reimbursement from the Drunk and Drugged Driving Prevention Fund (DDDPF).

eDSRS .m..l!.n be used by every licensed DUI Evaluation and DUI Risk Education provider in accordance with the provisions of the Alcoholism and Other Drug Abuse and Dependency Act [20 ILCS 301/1-1], and the rules and regulations promulgated under this Act, Part 2060. The forms, documenting the results of the DUI Evaluation or Risk Education, are produced from eDSRS and are the only documents that should be submitted to the Circuit Court of Venue or the Office of the Secretary of State.

Drunk and Drugged DritJing Preyentjon Fund

The Drunk and Drugged Driving Prevention Fund (DDDPF) was authorized by the Illinois General Assembly in Public Act 85-1304 in order to make Evaluation and Risk Education services available to DUI offenders who have inadequate financial resources. All providers with a valid DUI Evaluation or DUI Risk Education license must serve indigent DUI offenders and should submit bills for reimbursement using eDSRS.

The only reimbursable services from DDDPF are DUI Evaluation and DUI Risk Education. DUI Evaluations shall be limited to one evaluation per offender per DUI episode. DUI Risk Education shall be limited to one completed course per offender per DUI episode. For billing purposes the unit of service shall be one completed evaluation or course as described in part 2060. In order to submit a claim for reimbursement from the Drunk or Drugged Driving Prevention Fund, a provider must verify that the offender's annual household Income meets the following poverty guidelines issued by the U.S. Department of Health and Human Services, Washington, D.C. (Federal Register, January 26, 2017):

Number o1 Deoendents Annual Income 1 $12.490 2 $16,910 3 $21 330 4 $25 750 5 $30,170 6 $34.590 7 $39.010 8 $43.430

For each additional oerson add $4.420

The "Qualifications for DUI Services as an Indigent" form [IL-444-2034] is generated by eDSRS. This form and the most recently filed Federal or State Income Tax Return or any notarized document attesting to any change in status since the last filing must be maintained in the offender's record. Other supporting documentation can include and may help prove indigent status: unemployment security documentation, pension information, retirement information, pay check stubs, SSI, Medicaid IDHFS Recipient (ID card/award letter}, or a notarized affidavit of assets and liabilities. These forms and any supporting documentation should not be submitted to the Department of Human Services, Division of Substance Use Prevention and Recovery (SUPR).

eDSRS User Reference Manual I 2

The current state rate of reimbursement from the DDDPF is $135.00 for an Evaluation and $110.00 for Risk Education. The provider may assess an additional indigent fee if the provider's usual and customary charge exceeds the rate. In all cases, the indigent fee may not exceed the difference between the rate and the usual and customary charge for the service. All reasonable efforts shall be made to collect any assessed indigent fee from the offender prior to completion of the Evaluation or Risk Education service. However, if the fee is not collected from the indigent offender by the completion of services, the evaluation or certificate of completion for Risk Education shall still be released to the appropriate Circuit Court of Venue or the Office of the Secretary of State.

Claims for reimbursement wlll be processed in the order received according to the following billing procedures: Providers must submit a bill within 30 days after the end of the month in which the service was provided. Services to the indigent DUI offender must be complete prior to billing, Billing for partial or incomplete services is not allowed. Should two bills be submitted for the same DUI offender for the same service for the same episode, the first bill alone shall be reimbursed.

SUPR may conduct periodic post-payment audits of indigent DUI offender records for which reimbursement was sought to determine if the services billed for were conducted in accordance with the established standards and to ensure offender eligibility and financial status. If such audit reveals that the provider does not have the required supporting documentation, a demand for repayment will be sent to the provider showing why payment was improper. If the provider does not prove that payment was proper within 30 days of this notification, a "Final Notice of Intent to Recover Unsubstantiated Billings" will be sent to initiate recovery of the amount in question. Upon receipt of this final notice, the provider may request an informal review regarding the recovery of DDDPF disbursement. The request must be submitted in writing, along with any supporting documentation, within ten working days after the date of receipt of the notice. Providers will be notified of the resolution of the informal review. DDDPF funds will be recouped via certified cashier's check or money order due and payable within thirty calendar days of receipt of the final notice or ten calendar days after notice of resolution of the informal review, if one is requested.

Contact Information

Questions concerning the eDSRS application should be directed to the MIS Unified Health Systems Help Desk by email at [email protected]

Questions concerning DUI policy should be directed to the DHS Division of Substance Use Prevention and Recovery Help Desk by email at [email protected].


SECTION 2 - GENERAL SYSTEM INFORMATION

System Requirements All licensed DUI Evaluation and DUI Risk. Education providers must have internet service and maintain an active email account. Changes to email account addresses must be submitted to DHS/SUPR by email [email protected]. The following computer specifications were established by Management Information Services based on eDSRS requirements as currently developed. Your computer will need to meet (or exceed) the following specifications:

Required Internet Explorer (IE) Version 8 or newer Adobe Acrobat

Remmmended High Speed Internet Connection Wide-Screen Monitor (16x9)

System Security

or Mozilla Firefox - most current Version or Adobe Reader

To protect against unauthorized access, DHS Web Applications have a timeout functionality which automatically closes your session if no activity is detected between your PC and the Web Server for a period exceeding 30 minutes. If an Evaluation segment requires lengthy narratives which require more than 30 minutes to complete, we suggest that the segment be saved with minimal data, at which time you may re-enter the segment to complete the narrative. This will prevent loss of entered data if a session timeout should occur!

NOTE: Keyboard activity does not reset the timer. Only clicking a button on a page will reset the timer! After 25 minutes have elapsed, a warning message will appear with a 5 minute countdown to when the application will log you off. You have the option during this 5 minute countdown to click on the refresh button to continue.

The eDSRS application uses Transport Layer Security (TLS) encryption which is the industry-standard security system and meets the Health Insurance Portability and Accountability Act (HIPAA) compliance standards.

Worker Registration and Security Roles Each eDSRS worker must register with DHS in order to receive appropriate system access for their security role(s). Access to the UHS web-based application requires entry and approval of the email address used for registration into the Security Access Manager (SAM) as required by the DHS MIS Bureau of Security and Quality Assurance (BSQA). During the registration process, workers indicate the roles they desire and the appropriate approving entity will either grant or deny the access. A worker may have one or all four security roles.

Securitv Role Annrovina Entitv Resoonsibilities Provider Representative DHS/SUPR This worker is responsible for the overall operations at

the orovider, Provider Administration Initial: Provider This worker is responsible for daily business operations.

Representative A list of workers awaiting TAM approval will be displayed on the home page. This worker will manage

Final: DHS/SUPR Provider Entrants (change status to active or inactive, update credentials, etc). This role also may allow chanaes to Evaluations after marked as comoleted.

Provider Fiscal Operations Initial: Provider This worker is responsible for the financial aspect and Administration approving DDDPF bills for submission to DHS then

Final: DHS/SUPR tracking vouchers.

Provider Entrant lnitial: Provider This worker is responsible for entering Evaluation Administration and/or Risk Education data (evaluator /instructor),

Final: DHS/SUPR Provider Entrants must have the appropriate credentials in order to enter Evaluation information.


Change Password / Request User m Change By clicking on a the OPTION link at the top of the user's home screen, the user is given the option to change their password or request that their User ID be changed.

The following new window will appear. The user will then select the function they wish to do -Change their current password or Change their User ID and complete the required fields.

U5er N11lntel'IIJnc:e

Required Fields •

Cur..,..nt Pa-rd:

New Pau.of'd: • 1

Verify INew Password!

tf your Us;,u Id (eMa1I address) is changing ar,d you will still be employed bv the same Provider for which you used your current Id to logon to this Web Applic:11tion, you may request a user Id change. Th1:a-wlil preserve your ability to view current .snd past Evaluations and Risk Educations wh1~h you have entered m the System.

Once "'e have received your request, we will send an email to the ne,o, email addres9 you specified to verify that it "' a valid ema,t addreu and to verify that you do wish to change your User Id. Once you have responded to our email we will forward you~ request to DHS MIS Secunty to perform the change.

Current ll.er Jd:

N- Emall Add~ess:

Ae-Type New Email Add_,

• I

L ________________________ _:l:::s•=n=d=R=eq=-um\ ~ 1

Credential Update When Evaluators renew their credentials, the Provider Administrator is required to update the Provider Evaluator's credential expiration date in the system. The Provider Administrator can click on the Evaluator's name anywhere it appears on the website, the Evaluator Information screen will then show where the Expiration date can then be updated. After which the SAVE button should be clicked to save the updated information. If this is not done on time and prior to the expiration date, the Evaluator will not be able to enter data into the system.


P(l!U,IWoni;

Illinois statutas and OHS poliCIJ prohibit unauthoriud t1ecess: or diselosure of OHS dient, employee or cJny other confidenti-A1 information. Any unauthori~ed use of DHS computers or disclosure of collfidential client or emr,loyee information MllY bei cause for disciplinary ac:tior-., includina terminMion of 8mplo)'m&nt eind/or c:ttmfnll pros:ecutfon,

DD not attempt ID login unle5§ -,ou arc an aut:horlzed user. Bt Jo(Jglng mto tht!! uml,~d ,._!a8/J.h s1,;rem1 vsrM) vo,,r,,r t,SS(gned <1s-,r ID, rt,:iu ad<nowlf!Kir;,~ '""'e r<Jv ~re ar, aut/lorrZl!d u~er .tlfld -"'~ kl "'-)Kie /.J .I-' all roles and r~fl(Jl,,tiot>S oft/>~ /Jnl1iod H,a#h System, n is your Nsp,onsibmt.y to en1ure th& your /Ji'1f' 10 and pSHword an, kcl-'t.prfvare. Cl<J NOT sflarft your IOQtn 1t1format1on WJ(h anyone. fvo r~pre~r1t'/UJf:tP1tf af OffS wilt ever c,sk fat' your p,a1sword,

..:J

Toe Unified Health Systems eDSRS application may be accessed by entering the URL https://dui.dhs.illinois.gov/duisecure/dui in the address line of your browser. This is the first page that the user will see once they have accessed the Unified Health Systems application.

1. Toe user should type in his/her User ID. Toe User ID will be the email address used for eDSRS registration.

2. After entry of a valid User ID, the application prompts the user for a "Password". The user should type in his/her unique password. When the password is entered, it will not be visible. Passwords must be eight characters in length and contain at least one letter, one number, and one special character(#, @, etc). Toe password MUST be changed every 30 days to keep it active. For TAM password assistance, email the DHS MIS Bureau of Security and Quality Assurance (BSQA) at the following address: [email protected]. Or email the MIS Unified Health Systems Help Desk at [email protected].

• The user must not login to the application, unless the user has followed the logout procedures. To logoff the application, click "Logoff"on the menu bar at the top of the page.

• The user should only have one active session of Unified Health Systems running at a time.

3. Toe user must select "Login'~ Toe worker's eDSRS Home Page will be displayed.


worker Home Page

DUI Service Reporting System

U.- .J Arrr-;J l>tllf'Jl_. .... Ol{r-ltd(-r ~ •. (01J11lf •• h ... liW •..,

IIIC--dl--..

:-======::::1•-.·~· , ............... ,r·'7•C::::=====::=::~j et ===---=====~~ ~:::"1•-"·~··,~· :-""".........:====:::::~ ,AJ,.-,1 IHlt. "., OUrndirr~ •.., (.OUfflf ._."'- h&id1cw •• Ar,r,I b'tc: •.. tMi, 1, 1 '4- • founti, •• tiw-.ul:1>4' •• u.-b'IL ••

...... ... t..._ ___ _ I

The eDSRS Worker Home Page is displayed after logging into the application. The information shown on this page will be dependent upon the worker's security role. Help on the menu bar displays a drop down list which includes the eDSRS User Reference Manual, access to Provider Administration and System Message Administration functions, and information About the application and technical assistance information.

Active Evaluations/Risk Educat;ons will be displayed with Arrest Date/Time, Offender Name, and County. Arrest Date/Time is a link that when clicked on will display the Evaluation page or Risk Education page depending on what is in progress. Offender Name is a link that when clicked on will display the Offender Summary oage for the offender. Services Ready for Billing Approval will display the Evaluator Name, Offender Name, Completion Date and Service Type. Depending on the role of the worker there will also be a section for Notifications when a site's license or service provider certification/license are about to expire.

A Sort function is available at the top of each table. By clicking on the up or down ....... the column can be sorted in ascending or descending order.

Unlocking A Completed Evaluation or Risk Education

After an Evaluation or Risk Education has been completed and it becomes necessary to change its information, the Evaluator may "unlock" the record for data collection within the first 10 days. By clicking "unlock" and selecting OK on the window shown below, the record becomes active again and changes may be made. After the 10 day grace period, a Provider Administration worker may "unlock" the record for data correction using the same process.

Note: If an Evaluation has been Vouchered or is older than 180 days it cannot be Unlocked! If a Risk Education has been Vouchered or is older than 60 days it cannot be Unlocked!

l

Unlock

cl

' Unlock

- - - ----Windows Internet f.8plorer - ~:...:.....

we you sure you went to. Unlock the Completed Evalu11tion h11vlng S1 Ar'rest Date and Tline of 03/17/2811 - 23:00;00?

OK Cancel


SECTION 3 - OFFENDER INFORMATION

3.1 OFFENDER SEARCH

Name

Last Name: :·· · I Se srch Type: I Ex,:ict Match ..:.I First Name: I __ __J

Driver•~ License Number

License Number: :"

Date of Birth: I. Gender: I

Match Bv: I Exact M etch ..i]

City: L - State: l iJ Zip c:ode: ~--- _ _ l Countv: I Unknown ..:.I

search I Clear j Cancel I

Toe Offender Search page is displayed after selecting Offender Search on the menu bar. A search is to be implemented to determine if an offender already exists or will need to be added to the system. A basic search must consist of either Last Name or Illinois Driver's License Number. If Last Name/First Name is entered a Name Search Type may be selected for Sounds Like, Exact Match or Begins With to limit the number of matches. There is also additional search criteria which may be entered to limit the number of matches. After the selected information has been entered click on Search.

3.1 OFFENDER SEARCH -continued

' ..... Name

Lm Name: ~=~'------------ -~

First Name:

Driver'& Ucent,;e Number

License Number: !

Search Type: I Be.gins ·,IJith

Date of Birth: l"'littch By: I Exact Match _.ii Gender: I _3

City: ~------.........,. state: I _d Zip Code: ;_ _I County: I Unknol'fn .iJ

.. - . -.. . - . -. . -.

Add I Search I Cle11r j Cancel I


Search Resu Its No Results Found.

When it has been determined that the offender does not exist in the system, the Offender Search Results will be displayed with the message ''No Results Found'~ Select Add to enter new offender information or Search to search for another offender.

Name

l~ Name'. 'i'.!!_t,U

First Name:

OrN lllt'' • Ucense Number

Ucense Number"; :

Saarch Type:: I Begim; With i.] _j

__ 1

Date of IIIO'ln: i_

Gender: ~

·· ·, Natdl IJy, I Ex•ct Match _3

c:ttv! ! ·-· --~------- ~~ ~~--- ___ · __ : state~ I ZipCodo,: ' .. ::. :: ···- .I County; !unknown i}

~ s ~ ,ah / Cl~•r j Co~~ I

Search Results

Nsme

Mousrt, Mickey

Mou~, Minnie-

□IV Sliu e. Hh1:h0ate (iendct" 'lfc w

OctaJh

;;prirq)pl!!ltch IL 06/:28/2005 Mali!! Dehil!i

Sprin4Jpatch IL 06/::2.B/ZCI0S Female Details

When search criteria was entered and a match found, the Offender Search Results page will be displayed with a list of the Name(s) found for the match. Name(s) is a hyperlink which can be clicked on to add/edit Offender information. Details is also a hyperlink that will allow viewing only of details on the offender.


3.2 DUI OFFENDER INFORMATION

Alld DU.I Offender Info

Drlver'.li Llcell.58 Number(s) IL Driver 's License St<1tll s

R.equirsd Fi-eld& •

:I!), Driver's Llcerise ~vailal>le

Undooumented Immigrant

Out of i.t.ate r11eord does not exilll: at th is ti me

other (11.lterrii:lte Licen!;e,1! and O=ription belo.,.)

IL Licen!M: rtumber or Suit.! Jd: .. !. ________ _

Other License Number: ·------------' State·

Mdltlon11I Dernograr>hics Religion: "' f:;j Inteqm•tBr Servicss: • ,_,

Twin Indicator: i

Physical or Ment~I D1.s.,bility: •' -------- ·--·----· I

Courrtry: •1 ___ _

Employment Sbtus: j-;-J Occupatjon: •r --:::_

0 11.nnual Income NOT Discl06ed! 11.nnual Iocome: ~ __ _

Number of Dependent.a (Including Self): ~:

Emergency Cont11d Li:!st Name: •I ----- ----- Fir&t N.ime: • .__ _____ __,

Phone:

El

The Add DUI Offender Information page will be displayed when a person is found in the system and DUI offender information is to be added to the system. Fields marked with an asterisk. (*) are required but it is recommended to fill in all information that is available. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Offender Search page.

eDSRS User Reference Manual I 1 O

3.3 OFFENDER DEMOGRAPHICS

Dri-'.s 1)-Nu-(S)

Il Dnv'll!f"• LQ,w,e st.t¥J ~- t>nnr> Lico,_ svallab~

El

0\.-t :,t SZ.Ul ruoro ooes ~ a.ac •t V-• or.i-e-

· · Ur:iOco.me.,;t~ I~mti;1rant , • OU.r (Alttrr,■te ~Mil• •rdi l'e1er,p'tcr Odttw)

!L Li:e-"3e ~ '""'t-: ,- :-r Slat. Ia· • ' ---- I Twr Wabr. I I

-------- St.t: El Stlq!l ~ ; • t ______ _

I St.le.=: • ~ 11t~=c z,pc.- • - I . C-,Lrqy ..

PhoneNuMIIW'i ~Olflt!: Pl",c,r,e· .

...,,_.i D-tra,phica

.8 c~~"t,y " fJ ,..;,-:-Sto_!!< -

O.tc ~T' &111": • . ==---=-_-- ! ::I ~~- • • · --~-8 ~4rlt&t Slo!us: • ' · · ·

El "1i""'" 1.a.,,..,__ • El ~ s. .. = .

[] ... ,sol Ir-come ~OT°"""""°! ,..,,rul lr=ffle: • L---==NIJfflfle,c,1 Oe~nb (l~-•"9 $d) • 1--

-...,,y Cllll-

1.ao1 r.■-· ,r, --- --_-_-_-~::_:-J' r.-. ~ • ....,. •I-----~

P,>~""

El El·

The Add Offender page will be displayed when a new person is to be added to the system. Fields marked with an asterisk(*) are required but it is recommended to fill in all information that is available. When selecting Race information, select all of the race groups the offender appears to belong, identifies with, or is regarded in the community as belonging. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to create the Offender record and continue to the Offender Summary page or Cancel when information has been entered in error and is not to be saved and return to the Offender Search page.


3.4 OFFENDER SUMMARY

Oflendar SUmfnlJrJI

··• . ,. l.a.11 N1me.: House

f!Jnrt Hill ma: Mlnnle: Htddla I1til; J

Edit

..... StrnM Addr_..:. UU N. Matn

atv: li!>f'i11i11>1t<h Slate: 11111101s

ZlpCod o: U5 2& -u3.t Co onty: cha,._ign

Edit

~

Homo Phone: (211) 555-5555

Work Phone; Ext:

Cellular Phone: (:ZU) 555-55!15

Utt

'1,. P't'Mt Date/ Tim 11 •.., I County .... ]statu• ••

n.ucet\Se # or Slate ID: ,112:MS 678901

lie:._, Mliklld739d64jdy .. PJ.arlapa IJitandli 01:h11t' Ucen

Birth Oote: o 1 / 29 / 198D lil!nd er: female

JJ,ru;wl

Whltll

HJ.-panlc Ori til rn~ Mil!Jllcar,/ Maxi can Ahtttf"Jca n

aueae: Sign Lil no uaoe Prlm•rv Lan

Eduattion L evel: Hlgk och1MJI g,ad.,.t;e or ~ulvalency i:erHflcate

Employmant

AnnuaJ Inco

status: l:mphtyad oart tlfflfl (un.ub~idtz.ed)

mei 10891

epe•dants ( lnclud Ing self): 1 Numbe.r of D

a lif1cal1on Form I Wlew full oemographlu I !nd•i!•nt g u

" · Unh1ck ,......_ Arri1St oate: -.... Jcountv ~ [oispHftlan • ... !unlock ~.

No lfvaka~UOIIS lound ..• 12/ 10/2.010 Siiline :W) Tii!rminatell Ngl Applirabla

sttc , GJ f Ne,. J SIie: GJ I ~•w J

The Offender Summary page will be displayed when an offender name was selected from the Offender Search Results page. Hyperlinks are below each section to allow editing of offender information. If an Evaluation or Risk Education is already in progress, click on the desired date of arrest to access the data entry page. If there are no active Evaluation or Risk Education in progress, select the appropriate site then click on "New' to add the information.

The official DHS forms for Circuit Courts of venue and Secretary of State may also be printed from the Offender Summary page. The appropriate DUI service form can be printed by clicking the desired evaluation or risk education entry's status/disposition when the printer symbol is present. If the offender has qualified as an indigent, the button to print/view the form will be located in the Demographics section.

An Evaluation, or Risk Education, may be "Unlocked" from the Offender Summary screen. The functionality of the "Unlock" is the same as that on the Home page -

• Evaluators have 10 days to unlock a completed Evaluation or Risk Education. • A Provider Representative or Provider Administrator has 180 days to unlock an Evaluation. • A Provider Representative or Provider Administrator has 60 days to unlock a Risk Education. • An Evaluation or Risk Education which does not meet the preceding criteria, or one which has entered

the Billing process, cannot be unlocked!


SECTION 4 - EVALUATION INFORMATION

.-. - - - -· . - - ~ -- -- -...-.--_ ___,_ _ . - . · Evalua~~c:,_n,._ t---;:.__ p-~ ___ • ,

I Alcohol and Dn.la Related Leoa! a. Driving Hietorv I Significant AkohoVDruo Use History _ ]

Objed.ivli! Test Information I

Criteria For SUbstance Use Disorder I Off12n.der e Qha 11ior I

dassification/Mlnimal ReQLJired lntl'JVention J

~ Required lields have been entered ~ Required fields have not been entered

Note: Your session will be tenninated if no activity is dli!tli!cted between your PC and the Web Server for a period exceeding 30 minutes. If an Evaluation segment requires lenathv narratives whim require mere than 30 minutes to compfete, we sucge9t th.rt: the !legment initially be .saved with minimal d~.

Preview Evaluation Fenn I cancel !

The Evaluation page is displayed after selecting an evaluation already in progress from the Offender Summary page. A green checkmark ( ~ ) next to the evaluation sub-section indicates the information is complete and passed validation; no further required information to be entered. A red asterisk ( * ) next to the evaluation sub-section indicates the information is incomplete and all required fields have not been entered. The worker can save partial information (to be completed at a later date) without completing all checklist items. AU fields are hyperlinks and can be dicked on to access the information on the following pages.

On many of the data collection pages, the response to a question posed may require entry of additional information. In these instances a text box will appear for data entry. These narrative responses will be displayed on the official forms, as appropriate.

A DRAFT or "Preview" of the Evaluation form can be printed for review purposes.

When all information has been entered, select Disposition to finish the Evaluation process.

If the Disposition selected was for "Completed", the Alcohol and Drug Evaluation Uniform Report form can now be printed by clicking on Print/View Evaluation Form {Completed). If the Disposition selected was for "Not Completed", the Notice of Incomplete/Refused Alcohol and Drug Evaluation form can now be printed by clicking on Print/View Evaluation Form (Not Completed).

If there is a previously completed and billed DUI Evaluation for the same arrest date by another agency you will see the following appear at the top of this screen:

,~ .- - -:--;::-- - - ~ ~E~~ 1ri·dt~·o,i. . ~ - -- - - -- - -~ J'.'1e'wiuu•,i-., Bi~h.-<l to [X>L>l''I-" b'I' a d•th•ra•~I. P iro,,.iu1t~ "'°"" i,n PAJ.O•S.\-atu•,

4,1 CURRENT ARREST INFORMATION

Current DUI Arrest Information Result5

Referral Source · I ~o..':!_rt_

Beoinninc Dete of Evaluation:·• i04/W2oi3j 3

Date- of Arrest:• •041U1:20"'i"J"""" ~ Day of Arrest: Thursday

Time of Arre~: (nh: mm am/pm)• !!!~~ _I : iii_~- 11 f:'!'1~ ~\

Councy of Arre.st: , 1-Edwa r~---- · v !


~ Required Fi&lds

Blood-Aicotiol Con~ntration (SAC) at Time c.f Arrest:' -1~ - ______ : (Eneer 'RT' If '1.~iu5~c. Tost or '!'.A' for Not A.pplicable1

Was Blood and/or Unne Tasting performed7 If yes, ple11se provide results. ; C Yes (!) No

Specify up to five mood altering sub5tancss (alcohol/drugs) consumed which led to this DUI arrest (in order of • m05t to least).

l Non:earbitura~ ~edati,;~ -----~7 1. iMost consumoa)

I~ I

r=-, -

v7 2•

-., :3•

_- ,;.;; i 5 , (Least consumed.:

Arre!'t Substance Narrative

Specify the amount and time frame ir, which the e1lcoriol and/or drugs ~ere cons:umec! which led to this DUI e1m1st.

(::.oo char.act1trs max) You ha,e 500 charact~rs 1-.~,

I

I I I

_ _I Does the 6Iood-AJcoriol Cor,cer,tration ( BAC) for the current arres.t c:orrel11te with the offender's reporte<I consumption~ If no, please 8l(plain.

0 Y-es Q No 0 Not Applicable

This page is displayed after selecting Current DUI Arrest Information from the Eyaiyatjon page or New from the Offender Summary page. Fields marked with an asterisk(*) are required but it is recommended to fill in all information that is available. Dates may be entered or selected by dicking on the calendar and selecting the appropriate date. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Eyaiuatjon page.


4.2 ALCOHOL and DRUG RELATED LEGAL & DRIVING HISTORY

--- - - ---- ---- - - --- - - ---==- --- ------ ---------- ------... Ooc1> the ofl'endu hu~ "ny 4l~ohol and drug ,.,1.,1.cd dr-,iny infarmatio.n to I,,:, ~l>Qftod, ~n~ dixr~11•ne1~a b,:t.,.-~,, ,nlann,iti°" reported by the ofJcnd,or end infomi11t,on "" the: driving n:::ord1

CAUTION-: DO NOT [NCUJDE DIFOAN.I.TIOII REPOIOED IN na: FIRST ilE~ENT -- CURRENT DUI ARREST IIWOtl-TIO"' -- 1111 Tl115 Pll!DR H(SrORY :!iifCfIOI\I.

DUJ OispesRklns Prior a, Cu- Date of .l.r-

P1 101 DUI J !oLXA t 1~1's ,ociudio-;i bG.l!t,r,g <1nd soo·,.·m~bilino, (L&dli onoioa,c11llv, r,orn ~r.t fl.1re;t to rnon recent, ~n~ include out ---of•sleti::: e.1T-c.)t:»;l ;

DIITt,Of Ar~

( mrn / dd/yvvv)

~

oate Of CoroYWt>o"

or -Co u 11 !lu-,vi,.1011

{n1m/ctd/yyn, )

(Ad~.t«inal d1<pas,l1on• """"'<1 be !1'<-t•d ,~ an ;idd"1du,n te> the Uniform Ropon:) . - .

llfl>od AlcoHI CD'1Cefflr6110n

(l:nkr 'RT' iJ lldu!led f.,..l,

·11111· If Not AppfkAbki

or 'LIi<' • UllknltWn)

.c=1

. ,

. [.___...J

. I._____.

Sle l&J_.V' Surrun•rv(Xmplied Co1u,cnt ~en,....,. Prior la Current D•"" of ..,...,...l

,"'li,-io,r ~otuto,... -.,1rr,rTI1.1ir, or-.imp:'rcr.i r.ori"JC11'1- '!I0'1"it"nsi.-:t-n {m;lV' Ji"3Yc ~i:lrn~ ni,r~<:1t rtntC! of D.Jh :,'il.,.L'd -,bnVt:) 1

(mm/ cld /.,,,,,,,) i mm I dd IYnY)

.-==:,

,--::1

{A.ddt:on;;a,I diisFl'ca.iti &r,(; •hou·-d ita!. li~f:.cd 1ir, ~n ;;iidd<ind\.H"n to the U~ifc>•irn l\cpart)

a-cltle•s DnYing o,nwicii_,.. _r.., C::urN!•t llilh! ot Aff'@ort

....,<><I AIQ>tool c:01>.--•aaan

(l:ll'lc.- 'll T' W RdL1~..d T,.llt, ...... If Nat A1tpl1Cable,

Dr 'IJII" II UOll<IIOWII)

.1==-:J , l==-:J .c.:=1 .1==-:J

Pr>o.-ra~ll:la'-" d,-.ving con•~actocna ...,c1u~ed mm DI.ff (ma" riav• ..,,n., arrast cl.tit• ol'oun,mior'/ of•u-•mcl"I ,i,b!d •bova):

Date or ,.,_.

(mr11/dd/.,,.,,11)

~ ···- · '".".3

Dab! of Convictino

l ••m/lld/yyyv)

I --1 I :-!.I t :-:i , ,- --- - - --~-~

lllooll Alcoflol Cc.ncl'flt~ati<Nt {E11ter 'Rr ff a.tu-T•llt,,

'NA'. "ot At,t,llc,11i. ... or ·ua:· if U11mo,o,n)

,c=I , I I , L_____J

•~I - ~


4.2 ALCOHOL and DRUG RELATED LEGAL & DRIVING HISTORY - continued

Zero Taler•ncG Su,ipcnsions

Zero tc>leranc,i s"spe115ion, ""repcn•d by thee 0f.4n,:,;r 1~d/~r ,rd,cated on tt,., driv,rjl !'Ecord (10<lud1n~ 0111-of-!ltiU! d1sp ~~•!ion J) l

(mm/dd/wwJ -~,

3 1•<ll!ll•I Tr11n1portalion Cun,.idieAs

Eff..,tctin: D11t.:

(mmfdd/V.,.\IY)

lllogal tran6partation conv,rt,mB -ii re.p,:,rt~d by th11 olh,ndtr and:H indicat.id on tne cln,.,,11 rQc0rd tincl.,,fr.g <>~t-of .state di~po~itions):

Uatcof Ar~ U• ti: of <.:on v IC hon

Driving A.ccG I'd Discrepa,ncics

,/hre lh11rt 1ny d,r:creponciu be:,..•!en ,ntormal'IOP .-.part@<i i,.,, tha otf1n'it'r and ,niarm•bon on tl,e drt,ing reo:,rd? I• 'f••, pin .. provide re..~lt< . ..

. 'r'K ',_, 'Jc,

This page is displayed after selecting Alcohol and Drug Related Legal & Driving History from the Evaluatjon page and indicating there is alcohol and drug related legal and driving information to be reported. Fields marked with an asterisk(*) are required but it is recommended to fill in all information that is available. Dates may be entered or selected by clicking on the calendar and selecting the appropriate date. When a disposition date is pending or unknown, enter 01/01/9999 and "Pending/Unknown" will be displayed on the Alcohol and Drug Evaluation Uniform Report. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Evaluation page.


4.3 SIGNIFICANT ALCOHOL/DRUG USE HISTORY SigniflaJrtt Akoho//Dfllfl Use History Re5ulf5

· Requir!:1J Fields

Chronological Hi.story F-rovidc & complete and occurate ohronolog1cal hi~ory of the offender's alcohol ::,nd drug use from the onset of use up ta and including his/her last alC'Ohol/drug-related arrest and from the last alcohol/drug-related arrest through the date of this evaluation end/or curnmt abstinent da~ . .teport alcohol/drug use. by frequency, type, amount, and duration of $.aid patterns with a clear and complele e;,cpl1mation for any ~ariance in .aid patterns. This must include freQuency of into)(ications and any dru~ use, amounts needed t.o become Intoxicated. List the dates and locations of all prior attempts the offender has made to limit consumption or achieve abst1nern:e as a means to 11void any further consequences of substance use. Li~t the dates and loastions of all services the offender has received where substance use was a primary or contributing laotor for attendance. These can include, but are not limited to medical care , mental health services, relationship or pastoral coun~ehng, Employee Assistance Programs (1:AP), and StlJdent Asssstanoe Programs (SAP). List the dates and locations of all previous substanc;e abui:e treatment and intervention se,vices. I ndicate if mixed drinks are singl;, shot, doubles, or free poured: indicate if beers are 12-ounce, 16-ounoe, 24•ounce, 3~•ounce or 40· 01.Jnce containers; and fn.dicaU! the, glass size in ounces if con~umI1,o wtne or m1leed drir,lcs. Report offender's fil"St irtoxication and whether offender exhibited v·ivid recall cf this e~ent. Re,port when offender first exhibited alcohol and drug related problems.

Alcohol/Drug

1~ _____________ 3

----------

Chronologicel History Narrative:

!3000 chuicte-r!i m:a.x·:

..,.

Age of Frrst ~e

Age of Fln,t Age of

Intoxication llegular U,;e

(Ente~ 'NA' If Not Applicable)

Year of

Last U&a

You _h•~• _£hara <tors lalt. le$t ----------~--!

J Curr-ent tto,dlcatlons

R~view any prescription Of over--tne-counter msdication tne offren de'" is ~urrently ta king th!lt t,ai; the pcitenti al for i!lb..ise. Li9t the med;oation, wh"t it i~ used for, arld how long it has b.,.,,., taken, Report wheth .. r the offonditr has ever abused medication and whether he/,;he has ever illeg8lly obt<1ined prescn?tion mediC!ltion.

() 1-ppli~ble (!) Not Applicable

Fen,fly l'leml>er Addictions

5-1:>f!cily any immediate family member(s) with a history of alcoholi,m, alcohol abuse, drug addiction/abuse, or erw other problems rellll:ed to any suboruince abu•"· State. whether the fan,ily member is in frequ,:nt contact with the offender Md whether he/she is still usm11 anv •ub$tance.

('i Applicable (!! Not Applicable

Peer Group l\ddidions

Spectfv any 1rnmedn,te peer ~roup member(s) 'Nith a hi•tary of alcoholism, 11lcohol abuse, drug addiction/abuse, o,· any t>ther problem, related to any sub51:anct, abuse. State whether the. peer ~roup membel' ss in frequent cor>tad with the o~ender and whether h &/she 1s still u•1ng any substance.

0 Applicable ~> Not Applicable

Substance Uo;e

List all dates, loutions, and charges for wh,ch the offender has been arrested where sub.:tance use, po'ISes.sion, or delivery was a primary or contrtbuhng factor (including out-of-state dlsP->5itions): (500 charat:t~.-!i m~."'CJ You h.:1ve 500 chuact:~n laft..

Sic;tnificar>t Other Interview

Identify the ~ign iti cant other end summarize the information o.tltained in the interview.

(:I Applicllble (:i_l Not Af>plicabl1


Trelltment Program" Provide the name&, locations, and date$ of any trealmsr,t l)rograms repcrted by the c,ffender.

() Applicable ·~ l'Jot Applicable

Support Group" Provide the names of any self help or sobriety based su,iport group participation reported by the offend er ,md the dates of involvement

0 Applicathle (~'.· l'Jot Applicable

lmpalnr,enb H~s substanc" use./ abuse negzibvely impl!cted the client's major 1;1'1! zireas?

(300 characters ma-x~ ~~ve: char1ct@r!!I l~ft.

test

(~_f Applicable (l l'Jot Apphcahle

Harriage or s ignificant other re lat[onships

Lnqal "tat.,.. Q Applicable (!'! Not Applicahle

~ (i Applicable (~:J Not Applicable

vocational/ work Q Applicable 0 Not Appl ic:able

Economic uatus ( ) Appliczi~e (!_"\ Not Applica,ble

ftl:,f1il91!hi!l tjealth () 11.pplicable ~I Not Applicable

•~) Nol Applicable

This page is displayed after selecting Significant Alcohol/Drug Use History from the Evaluation page. Fields marked with an asterisk(*) are required but it is recommended to fill in all information that is available. Dates may be entered or selected by clicking on the calendar and selecting the appropriate date. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Eyaiuatjon page.

After completing the chronological narrative there are several areas to add specific information. By checking applicable, a dialog box will open that will allow you to enter relevant information. In the section titled Impairments, almost all cases should include some applicable information. Such as in legal - - it is apparent that the client had some legal issues since they have at least 1 DUI. This may have also, impacted other life areas such as economics, family or social life.

4.4 OBJECTIVE TEST INFORMATION

Objective Test Informdfio11 llesult5

Mortimer/Filkins Score: I_ ~~:::~ _ _I Cate gory:

Adul t Substance Use and r"'3 Driving Sur.ey (ASUDS) ... Score:

Driver Risk l nvento ry (DR!) Scales and Risk Ranges

Validity Scale:

Alcohol Scale:

Driver R.i,;k Scale:

Drugs Scale:

Stre~ Coping Abilities Scale5:

.i.l


*" Re.suits from ;,t least one test is required ...

1 Saw I Cancel 1

This page is displayed alter selecting Objective Test Information from the Evaluation page. Fields marked with an asterisk (*) are required but it is recommended to fill in all information that is available. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Evaluation page,


4.5 CRITERIA FOR SUBSTANCE USE DISORDER

substance Use Disorder Results

SuHlance Use Disorder Cril .. ria Identify any Substance Use Disorder Crlteril!I occurr ing within a 12 month periad. Tr.is may be done using the offender's current presentation or a past episode for wriich the offender is currently asoses&<!d a,; being in rem1s.s1on. 011e ~ymp-t:orn wHI r esult In a Moderate Risk Level classificat10n. Two or three symptoms will result in a Significant Ri&K classificatfon. Four e>r more symptoms will rosult in " High Risk cla.s&ification.

r...:-1 Alcohol or dru<JS are tat.ten in larger amounts or over a longer period than iritended.

c:1 There is a persistent desire or unsuccessful efforts to cut down or control alcohol or drug U!".e.

c, A gre11t de-111 of time is spent in ectivities nece~ary to obt11in, use, or reco1ter from the effects of alcohm or drug use.

= Craving, or a strong de:.ire er urge to use alcohol or drugs.

c ~1 Recurrent a,lcohol or drug u,;e use resultir1g in a failure to fulfill major role obligations at work,. school or home.

,:._; Continued alcohol or drug u:.e despite havir,g persister1t or recurreflt social or interpersonal problems caused or elCacerbated by the effects of alcohol or drugs.

, __ , Important s;ocial, occupational, or recreational acti1tities are given up or reduceo becau1..e of elcohol or drug use.

ccc, Recurrent alcohol or drug use in ,ituations in which it i~ physically ha2.ardous.

u Alcohol or drug use 1s coritmued d~pite knowledge of having e pen;istent or recurrent physical or psycriolog1cal problem that is likely to have been caused or =cerbated by alcohol or drug">.

= Tolerance - Either a need for markedly increased amounts of alcohol or drugs t o achieve intoxication or the d10&ir"d effect, or a markedly diminished effect with continued use of the same amount of alcohol or drugs.

,_, Withdrawal - As manifested t.y either the characteristic withdrawal syndrome for alcohol or drugs, or alcohol or drugs are taken to relieve or 11void withdrawal:..

llemi-lon Status If tll" off.,nder meet,; Substance Use Dis.order criteria based on a pas.t episode and is now asses:;ed as being in remission, identify and dascribe the cour&e specifier that reflects the oFfender's current status. Early Remissi on: ,t11,fter full J:rileri.a for Substance u,.e Disorder were 1>re-violl"tv met, none of the Subt.tance Use Disorder criteria h11ve been met tor at 1 .. ast: 3 month,. but leo;s than 12 months. (With the exception of craving, or a strong d..,.i,e or urge to use alcohol or drugs)

Remi..,.ion Status Narrative

Written n11 rrirlive . ..

Prior Hmorv Has the offender ever met SuP~nce Use Disorder criterra by prior history t.ut is now con!.idered ~ecovered (no current Sub5tance Use Disorder s)? If ye&, pleaM! e:xplaln when the crit eria was met and why it is not clini~lly s1gnif1cant for the purposes of a current risk assessment. The exp!'!ln11tion must include the len~th of time ~ince last e~isode, the total duration of the episode, and anv need for continued evaluation or monitoring.

y"

Substance U&e Disorder History Narrative

Written narrative ...

This page is displayed after selecting Criteria for Substance Use Disorder from the Evaluation page. Fields marked with an asterisk(*) are required but it is recommended to fill in all information that is available. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.



4.6 OFFENDER BEHAVIOR

Add Offender Behovior

... Required Fields

Offender Behavior Rcs1tonses

Were the offender's l>i,hl!lvior and respol'l8el. consistent, r:!-liable, 1md non-evasive? (BOO characters ma)() '.fou hav"' characters le~ __ . ____ _ _ ___ _____ _

Offender Behavior Disorders

Identify indications or any $ignificant physical, emotiQnal/mental h.ealth, or 1>5ychiatric di:r.e>rders. (BOO characters max) \lou have charact11rs le~, _ _____________ _

Offender Behavior ~istanc:e

Identify any special as:.iitance provided to the offlmder in order to complete the evalu!!ltion , (BOO C"haractars max) '1' Du have characters left,

--~--____ ] Offender Evaluation Location

Where wa.s the offender interview conducted? !I=

0 Liceni.ed Site O Non-Lic!!lnse<! Site

j Save ] [ Cancel

This page is displayed after selecting Offender Behavior from the Evaluation page. Fields marked with an asterisk (*) are required but it is recommended to fill in all information that is available. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Evalyatjon page.

eDSRS User Reference Manual I 2 I

4.7 CLASSIFICATION/ MINIMAL REQUIRED INTERVENTION

Add Classlflc11tion//llinim11/ Required Intervention

' Required Fields

Cl11u;ific:ation! l'loderate Risk

Di6cuss how corroborati-.e information from both the iriter>.iew and objecti\le t&.t either correlates or does not corr-cl~te with the information obtained from t he DUI/alcohol/drug offender,

(500 characters max) Vau ho•,~ charact&r> h>ft.

.:.I

Minimal Required Intervention:

HODEllATE RISK! Completion of a minimum of 10 hours of DUI Risk Education, and a minimum of 12 hours of e.irly Intervention provider over II minimum consecutivia days, J11ubsequent completion of any and all nt1ccssary of four wee.lea with no more than three hours per dav in any seven treatment, c1nd, after dischuoe, activr. on going p.utlclpation in all activities ~pecified In the continuing care plan, If so recommended, following completl()n of the early intervention.

The offender was referred as follows; (250 chara1cters miiX:j You ha,._.& charac:te:rs le:~.

.:.I

.:J

This page is displayed after selecting Classification/Minimal Required Intervention from the Evaluation page. Fields marked with an asterisk (*) are required but it is recommended to fill in all information that is available. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.



4.8 EVALUATION DISPOSITION

Add Disposition

Dispos~ion

Completion D5~ c,f Evaluation:

Number of Appain tments:

Hours for Interv1e111&:

Hours /or Paperwork:

0 Adwetln Proo

~l Completed

0 Not Complete

0 Entered in Err

, 0S/16/2013 . ~

. ~-=--1 ·L.J , 12 I

J; By selectlnq "OK", you wij save this evaluation as ,ompleted, You will be alowed to unlock this evakiatlon for 10 days to mBke chanoe:;, After thelnitlal 10 days only an agency admlnislr a tar may unlock a closed evatuaoon for the original e11tr ant to make addtional cha191; and updates, The administrator may unlock evaluations for !80 days or until the evalua~on has been bled/vouchered to tha department whimever conies fir~,

If you are not ready to cC111plete tris evaluation, select 'Cancel",

OK ) [ c~cel

This page is displayed after selecting Disposition from the Evaluation page, Fields marked with an asterisk (*) are required. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page. Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Evaluation page after the verification process is complete.

When Completed is selected, the screen will expand to collect the date on which the evaluation was completed.

Di~o.-ition

Complet+on Date of Evaluation:

r Active/In F'mgress

r. Com~eted

<"' Not Compllrted

r E nteraij in Error

• l __ ____,I [j

Select Save to save the information as Completed. The following window will appear for verification. After selecting OK on the window, no changes can be made to the Evaluation information.

J; By sel"dfno "OK'", you win be allowacl to save tf,js evaluatjon .as completed and you will be prevented fr= making additio"-ll wpdates to the Information.

If you are not ready to complete this eva.uatilrl, select "CM\ci:,l",

OK Cami


4.8 EVALUATION DISPOSITION - continued

When Not Completed is selected, the following screen will appear to select the reason why the evaluation could not be completed. NOTE: Entering Not Completed will make all previously entered information inaccessible. Do Not enter a Not Completed if you wish to access this information at a later date.

Incomplete Reason r Offender would net sign the infe>rmed con~nt form

r offender did nc,t return to o.btain a copy of the evaluation within 30 days

r Offender did not return to sign II copy of the evaluation within 30 days

r"" Offender refused to sign evaluation

r Offender refused to accept evaluation

(' Offender did not complete the evaluation

r Other

Select Save to save the information as Not Completed. The following window will appear for verification. After selecting OK on the window, no changes can be made to the Evaluation information.

? By selecting "OK", you will be allowed to save this evaluation as not completed --~/ and you wm be prevented from making additional updates to the information.

If you do net want to mark this evaluation as not completed, select "Cancel".

or. Cancel

When Entered in Error is selected, select Save and the following window will appear for verification. After selecting OK on the window, the Evaluation information will be permanently deleted.

? . By selecting "OK", you wiU be <lilowe'd to remove this evaluation -i / end the lnform~tion will be permanently deleted.

lf you do not want to detete this evaluation, select "Canrel".

OK C11rn:eJ


SECTION 5 - RISK EDUCATION INFORMATION

5.1 RISK EDUCATION

IAaa RJ;;k Education

• R.equi red Fields

Offimder Iriformatlon

Last Name: fla"ders First Name: Jack Middle. Initial: A IL Drivers Ucense: ABC123456789

Arrest 1 nform zrtio"

D~te of Arrest: • :. _ ~ -_ .1 3

County of Arrest: • j iJ Attendance Date!!.

Date ,: - 1 : ~ Date 2: ____ -~ Date 3: ! __ ___ ___ } ::) Date 4 : '---~' 3 , Date 5: : . __ =_-_-__ ' 3 Date 6:

Tl!!st Scores/Hours Met

Pre Te5t Score: 1{ ______ 1 Port Te"t Score: r--1 I

I) Houn; Met Ind,cator: r,

j Hours Met Narrative:

~250 c:h 11racters ma>e; Yo" h•"" characters loft,

r No

~ Date 7: [_ ~ 3 Date 8: · _I ~

_:J

Complehi/Terminete

-

Save I atnceJ I

The Risk Education page is displayed after selecting a risk education already in progress or New from the Offender Summary oage. Fields marked with an asterisk(*) are required fields but it is recommended to fill in all information that is available. Dates may be entered or selected by clicking on the calendar and selecting the appropriate date, The worker can save partial information (to be completed at a later date) without completing all items. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Offender Summary page.

If a previous Risk Education Certificate has been completed and billed by another agency you will see the following at the top of your new Risk Education Certificate screen:

Prev+u u,.jy: 8iUe'd to OOOPF bv u d,~ent Pn:,v,(le no"' in PAID St..tu:,


5,2 RISK EDUCATION DISPOSITION

Select Complete/Terminate on the previous screen to enter the disposition. Toe following window will appear.

Message from webpage ~

CAUTION: DO NOT Bill THE STATE UNLESS THE CUENT HAS SJGNED FOR AND BEEN GIVEN A COPY OF THE UNIFORM REPORT af\d or THE DRE CERTIFICATE!

By selecting "OK", you wm be allowed to complete or terminate

this Risk Education course. You will be allowed to unlock a completed Risk. Education for 10 days to make changes, After the initial 10 days only an agency administrirtor may unlock a closed

Risk. Education cours.e for the original entrant to make additional changes and update5. The administrator may unlock Risk Educations for 180 days or until the Risk Education has been

billed/vouchered to the department whichever comes first.

If you are not ready to complete this Risk Education, select "Cancel".

___ o_K _ __,] [ Cancel

After selecting OK on the window above, the Disposition area will be displayed on the screen. Once the appropriate disposition has been saved, no changes can be made to the Risk Education information.

Di.5po51tion 0

" Only finish this 1.ection if you are re'!ldy to complete or terminate. u.-

Disp~ition: • I Completed r- TermiMted

Disposition Date; · : _________ ; 3

Termination Reason: •

(2:50 charac:ter, maix; You l'liwe char.iiicters le:ft,

-. Save I C11ncel I

Once the Disposition is selected, the Certificate of Completion or Notice of Involuntary Termination form can be printed from the Offender Summary page. Risk Education Certificate of Completion forms may be run within 6 months.


SECTION 6 - PROVIDER INFORMATION

6.1 PROVIDER INFORMATION

Provider Sum1111Jry (PravJdw: Test Provider)

Pl'9vider N11""': Tt!Sl Provider FEIN: 123456119 OASA Provider ID: 9999

5tre-M Add,.-: 1313 Kockl"lblNI ln

cnv: SOrtft,a~tdl state: llllnOI• Zl.,Cod11: &2701 County: Sangamon

Phof'II! NumlN!ri (2. t 7) 5SS• 55S5

~hK11nt•tive on flle - Ni.me; Hennen ""nster P11011e Numbc~ (111) 555-999f 1:ma;i AddN!M: TestPNFv• wwtc.com

MNw: ll'urihtnl by Se<ur,ry lfiok:

l!ta!t1$1!Cf IIDNlHl!l~HU

• .._ ... "'9nsle, ( DUll"SIOJ) ll.,Qlo<...-

Proxidi:r .Ad'.lllll.!w:41.!ll.!! • ..__,,,._. __ (DUIT51D1) ·-

PrO\,i!U!...f.11.<4 I Oper9t,ons

No Wortu1n found!

- me,-, ..J - -(t•cen~ t:J1114rc1tt0n llcenH N,11t1be-r Stte Name Date -

I A•9999·0000•A Test Site oti/ ~0/Z012

-s .. .~ .jHol - , fvelu11,or N.Jrne -0:.. f ,11,,11 Addre,;'l "'• I t:mploymcc,tlRolc

st.aolut. "'• Removal .....

Mennen ll'lunster OUtlST-Ol .l.Q,ve l.trl,o\·t-I .

Select Provider from ttie menu bar to display the Provider Summarv page. Basic provider information on file with DHS will be displayed along with active workers by approved provider level security role. All licensed sites and evaluators will be displayed in a table format with a hyperlink to detailed information. Click on the Evaluator Name hyperlink to view/change information on an evaluator.

Provider and site information can only be changed by the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery.


Removal of Workers

Next to each worker's name on the Provider Summary page, after each Security role, there is a link C'Remove) which allows the removal of a worker from that role. A Provider Representative may remove a worker from any role; however, Provider Administrators may only remove those in a Fiscal or an Entrant role. In the list of Evaluators this functionality is located in the last column of the Evaluator table. When "Remove" is clicked, the following screen will appear -

The lndlvld11al Indicated belo,~ v,ill be removed from the ,;;pecifled Role:

Provide~ Adminidrator

User: de url'lelllamerltech.net (Currie, David)

D Remove User from all DUI Role"

Note, Once all role, have been removed, a user they will no lonoer be able to logon to the eDSRS Web Application; however, all prior Evaluations or Risk Educ8tions performed .. ill be maintained and identified as beino performed by the user after removal I

If the worker is no longer actively employed then you may check "Remove User from All DUI Roles" which will permanently close the worker and disassociate the worker from your Provider. If the worker is on temporary leave, it is best to mark the Evaluator as "InActive" which will prevent the worker from logging on but will not require the worker to repeat the Registration process once they have returned.

Note: 1) The worker will still be identified by name on all prior Evaluations or Risk Educations! 2) If the worker belongs to only one role, and is removed from that role, the worker will be dis

associated from your Provider

6.2 SITE INFORMATION

Lh:ense Nu mber: A-9999-0000-A Site Name: Test Site

Approval D11te: 07/01/2011 Expiration Date: 06/30/2012

Effective 011te: 07/01/2011 Termin11tion D11te; 01/01/9999

Street Addre55: 1313 Mockingbird Ln


Citv: Springpatch state: Illinoi" ZipCod e: 62701 Cou nty: Sang111mon

Phone Num ber: {217) 555- 5555

Representative) Name: Eddie Munster Phone Number: Email Address: [email protected]

Services Provided • DUI Evaluation • DUI Risk Education • Level I outpatient {Adult) • Level I Outpatient (Adolescent} • Level U Intenfiive Outpatient (Adult) • level [I Intensive Outpatient (Adolescent)

The Sjte Informatjon window is displayed a~er selecting Provider from the menu bar and clicking on the License Number hyperlink for a specific licensed site listed on the page. Close the window to return to the provider Summary page.


6.3 EVALUATOR INFORMATION

Add Evr,Ju.,tor

Evaluator Information Evaluatcr Email Address: JH1ppyilj:,h ome.com

• Required Fields

Last Name:·;______ _ ____ _ ···-_-~·-1 First N8me: ·I~--- Middle Initial: i

DUI Crientatio.n Status: r Yes (.' Ne

Employinenl Status: '" Active r Inactive

"'""' At le 11st cne E.x.piraticn Date must be entered "~~

Credenth1ls

Certified A-dYanc.ed Alcot>ol B< Other Drug Abuse counselor (CAADC)

Certified Alcohol,. Tcbaccc & Other Drug Abuse Preventionist (CAD~) - Risk Ed Onlv

Certified A.lcohol & Drug Ccunselor (CAGC)

Certified Assei;sment & Referral Specialist (CARS)

Certified Reciprocal Alcohol & Other Drui;i Abuse Counselor (CR.ADC)

Certified Supervisor Alcohol & Other Drug Abuse coun&elor (GS:.DC)

Ce~fied Senior Alcohol, To.b~cco S. Other Drusi Abuse Pre.,,cntioni5t (CSADP) - Risk Ed Only

Doctor of Medicine (MD)

Doctor of Cs.teopathy (DO)

Licensed Clinical Profes!.ional Coum;elor (LCPC)

Lice11sed Clinical Psychologist (LCF')

Licensed Clinical Social Worker (LCS•t:)

Licensed Professior,al Coun:.elor (LPC)

Licensed Social Worker (LS'N)

Expiration Date (mm/dd/vvvv) I --7:-,;I --- ....::J __ J ~

-=======-1 ~ r======-• 3 r~--'3 I JG L~-- I ~ I- ______ I ~

1-=====-•i 3 - 12'.j

- -1 ~ _ _ _J C'.'.]

1-:=--13

The Evaluator page will be displayed after an evaluator was selected on the Provider Summary page. Fields marked with an asterisk.(*) are required fields but it is recommended to fill in all information that is available. Dates may be entered or selected by clicking on the calendar and selecting the appropriate date. If the entry has an error(s), a message explaining the reason for the error condition will be displayed at the top of the page.

Select Save to save the information or Cancel when information has been entered in error and is not to be saved. This will then return to the Proyjder Summary oage.


Evaluator Maintenance

Under the Provider tab on the Home page, there is a drop-down selection that can be used to change the assignment of an Evaluator to Evaluations and/or Risk Education Certificates.This function can only be accessed by those individuals who have registered with the Provider Representative or Provider Administrator role.

First hover on the Provider menu item - then click on the Evaluator Maintenance option that will appear in the drop-down. Once that is done the following window will appear.

E11aluator Hamtenance

Eva!.&tor Milffll:t!IWROI! - - ••• - • .

Criteriil for Trilnsfer {Sbtw;) Only 11.ctiva Evalw.-s or Adive llkl; Ed111:-,a; fflilY be trannen-..i ,rt the ~ 1,,.,1!!1. If~ d.ata ,--.. llD ba tr-.ferm, --contact SUPR. fur ,.,5nbnce!

~ • .,_crive, Actiw RlaviHd

C:o "'IU•~•, '9ma~ 11,o,,i~!!<I E.•,EerH 1n l!ff.., T!!iw..,_alei

Sourca and Targ1 E..aluatat So'-'rcli Eviilu~r. ,-------------v-, Targ"" Evaluator:

Situ fauncl,.,,, ~ E,,.,L,.ator

V

Only Evaluations and/or Risk Education certificates having a Status of "Active" or "Active Revised" can be transferred from one Evaluator to another at the Provider security level.

Once the appropriate Source Evaluator (the individual who created the Evaluation/Risk Education certificate) is selected, the Evaluations and/or Risk Education Certificates currently associated with that Evaluator are displayed by Site (shown on the next page). For each Site displayed, the option of "None", "All", or a specific Evaluation and/or Risk Education certificate must to be selected for Evaluations and Risk Education certificates displayed for each Licensed Site. The Target Evaluator must also be indicated prior to transfer. An Evaluation and/or Risk Education certificate may be transferred to a different Licensed Site number; however, the default sets the Target Site number to that of the Source Site number.


E11a/uator Haint.,,,..,.r;.,

• ·_ __ _ __ ~Ewil~~:--· ---~- ____ ••

Critariao for Traonffi!I (st.tus} Only Adln Evaolu•tions or Active Ri5't Edlfations may be transferTed at the Provider lewl, If Completed data naads to be tr.anda1Ted, .,...,,., u,nbd SUPR for assistan ce!

~ • ,'icriver Activtt ~:Sid

GI, ............ '•"'flleti>o Ao.lseil, i;....,,... '" '-Fer. Te"" aee Source ~ Tarqat Evaluator S<.o,,ce E•••U<1torc ' j~tm---..,-.-.vaJ~u-•·-,o-, (-,,.im- d~u-le-va...,l@,c-.-du71.-co-rr..,.) ____ v...,j

Ta,vet E-,,aluaro" '

Sit.,,. founcl for S.,..C,. Evaluator L·c..nc .. "'"'"be" A· 05!19-0011-A S'te tl.ame: HE'.LrHCAAE ~.LTERN,'.TIVE SYSTEMS, INC. ~dcrus: 11l5 N 23RD AVE, "lELROSE PAAK

;,,iumoer af faa,ui>tO""' 2 N um~r ol Risk Educations, O

Once all required fields have been entered, Click the "Process" button. When the transfer has been completed the following window will appear to the right of the Evaluator Maintenance window or it will appear just below the Evaluator Maintenance window depending upon the resolution of your screen.

-

Sou,-it:e Pr-avid IP!,r: .HEAL THcAA.E ALT EJtNATIVE SYSTE"S, INC.

S11ur'=e Ev.,luat:o~ air-rt.e, Dav1d Taf'get Evaluator. FJandril"$, lack T

Lfcenu Number; A· 0589· 0001-A lR Lla;ou; Number· A-0589· 0001-A

L evilluallon for sn111h, Bob with an Arrest Date aBd T l tr1e of 05/2-4/2011 - 12:3 0 PM tran,1;fcrred •.•

I Priot '

This new window displays a numbered list of each Evaluation and/or Risk Education Certificate which was transferred between the two Evaluators by Licensed Site number. This window is printable so that you have a record of the transfer.


SECTION 7 - DDDPF BILLING/VOUCHERS

The DDDPF Billing Approyal and DDDPF Vouchers pages are displayed by selecting 811/ing from the Menu Bar and selecting either BH/ing Approval or Vouchers from the drop down list.

7.1 DDDPF BILLING APPROVAL

DDOPF BilliTfll Approval

r Sel<KtiDu,al<>ct All for Approval

Apl)(oval llk!icator Servla lype Evat .... tor N•m11 Complatlon o~i:. 8 111 Amount

The DDDPF Billing Approval page displays the DDDPF billings for DUI offenders that have met the qualifications for inadequate financial resources. The type of service, evaluator name, offender name, service completion date, and bill amount are displayed on the screen. The Provider Fiscal worker must mark. the Approval Indicator in order for the bills to be submitted for reimbursement. The approved billings are collected and processed by DHS on a weekly basis, normally on Sunday evening.

DDDPF bills will only be displayed and billable when they are within the last day of the succeeding month from the completion date of the service. If the DDDPF does not have sufficient funds, no bills may be submitted to DHS.

Upon clicking "Save", you will be prompted to verify that the offenders are all indigent and payment was not received for any of the Evaluations or Driver Risk Educations which are being submitted to the DDDPF.

Message rrom webpage

CAUTION: DO NOT BILL THE STATE UNLESS THE CLIENT HAS SIGNED FOR AND BEEN GIVEN A COPY OF THE UNIFORM REPORT and or THE ORE CERTIFICATE!

I have reviewed and verified each client record ta ensure that the recordcontains documented proof of indigence. I have further verified for each Evaluation or Driver Risk Education submitted to the DDDPF that the providerhas NOT received payment from the client which exceeds the difference betweenthe current Fiscal Year State rate and the provider's usual and customary chargefor the service!

__ o_K ____ l I Cancel


7 .2 DDDPF SUBMITTED VOUCHERS

DOOPF Submftwd VoucMfS

The DPDPF Submitted Vouchers page displays the submitted vouchers with the Voucher Date, Voucher Number, Total Amount, Voucher Status and Warrant Date.

The values for Voucher Status are: New DHS Comptroller Paid Voucher Missing

no voucher has been issued is in processing at DHS, not sent to Comptrollers has been sent to Comptroller's Office, no waiver as yet Comptroller has issued a warrant and voucher is missing from DHS and Comptroller's office

The Voucher Number is a link that when clicked on will display the Voucher Details page. This page will display the breakdown of billing information on the particular voucher.

Voucher Number: LDD0007l3

Offendar Name BiJl,.,_t


SECTION 8 - REPORTS

The statistical reports are generated by selecting Reports from the Menu Bar and clicking on the desired report from the drop down list. Available reports include:

• Evaluation Statistics- displays offender and select evaluation summary information • Evaluation Services - list of offenders receiving evaluation services • Risk Education Statistics - displays offender and select course summary information • Risk Education Services- list of offenders receiving risk education services • Evaluator/Educator Info - list of entrant role staff and their credentials • DDDPF Billing - list of offenders qualified for billing and corresponding bill/voucher information • Provider Worker List - list of active workers and their security role(s) approved during registration

The following window will appear for those reports requinng additional selection options. The service completion begin date and end date will contain default dates and may be changed to the desired period, Reports may be generated for a single site or all sites for a provider. After the selection criteria are entered, click on Print/View Reportto produce the report or Cance/when the report is not to be generated.

llegi" Date: 1@.!ll~ 3 End Date: l~ l.i~!ll 3 Site: I All Site& ..J

. Print/View Report! cancelj


SECTION 9 - RESOURCES

External Web Sites • University of Illinois in Springfield - this web site link takes you to the center for State Policy and

Leadership - Institute for Legal, Legislative and Policy Studies. Here you will find information on DUI Service Provider Training and contact information.

• secretary of State Cyber Drive - this web site link takes you to Jesse White, Secretary of State's web site for the Administrative Hearings Department.

• eDSRS Registration - this link will take you to the web site where new eDSRS Evaluators/Users can register for access to the web site application.

Forms • Informed Consent - English • Informed Consent - Spanish • Referral List Verification - English • Referral List Verification - Spanish • Backup/Draft Uniform Report

Instructions for the Backup/Draft Uniform Report: To obtain a Backup/Draft copy of a Uniform Report that you can use when the system is not available, follow these instructions: • After logging into the eDSRS system, use your mouse to activate the drop down menu for

Resources. • In the drop down menu under Forms, select Backup/Draft Uniform Report. • The screen below will then appear giving you the option to complete as is and print or to save to

your computer for later use. • This form can only be opened and saved while using your internet browser. So you can save it to

your computer hard drive, then when you want to use it later you will need to open it while you have your internet browser open.

To print, click on the printer icon ~-,.."'•-~ n.,...,..., ~ X.- "'"r,V:•~

.. ~.fo~l .1 nd Dr1.1, E \ ilh1,1 l'io.n r oi.r,ei,1 1111 'Rtp,ol r

~E'WBPlOR.\l\TlOS

d. thi,n'i l.Mf•w.'lo_.....« ~.ll'r [I)·,

Ollin \ ,IOd Dm·r, < lJit,,1n, SIIIIIN'1 '\&IW:

DUI Information

( .. al\ rJtr-•SM:it:

(ltl,1,w~:

·J

The following links will provide you with PDF copies of the brochures that explain the DUI processes and evaluations:

• Processes and Evaluation - English • Processes and Evaluation - Spanish


APPENDIX A - DHS FORMS


IL444~2030 Upon successful completion of an alcohol/drug evaluation, the DHS Alcohol and Drug Evaluation Uniform Report form (IL 444-2030) shall be provided directly to the circuit court of venue and a copy given to the offender.

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IL 444-2031 Upon non-completion of a DUI evaluation, the DHS DUI Evaluation Notice of Incomplete/Refused Alcohol and Drug Evaluation form {IL 444-2031) shall be sent within five calendar days to the circuit court of venue or the Office of the Secretary of State, whichever is applicable.

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IL444·2032 Upon successful completion of a risk education course, the DHS DUI Risk Education Certificate of Completion form (IL 444-2032) shall be issued to an offender.

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IL 444-2033 Upon termination from a risk education course, the OHS DUI Risk Education Notice of Involuntary Termination form (IL 444-2033) shall be sent within five calendar days to the circuit court of venue or the Office of the Secretary of State, whichever is applicable.

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IL 444-2034 Upon verification an offender meets the poverty guidelines issued by the U.S. Department of Health and Human Services, the DHS DUI Evaluation/Risk Education Qualification for DUI Services as an Indigent form (IL 444· 2034) shall be maintained in the offender's record.

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APPENDIX B - SAMPLE REPORTS

EVALUATION STATISTICS

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eDSRS User Reference Manual I 5 5


EVALUATOR/EDUCATOR INFORMATION

DDDPF BILLING

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HEARING REQUIREMENTS

Office of the Secretary of State DEPARTMENT OF ADMINISTRATIVE HEARINGS 601 S. 2nd St. 17 N. State, Ste. 1200 Room 212, Howlett Bldg. Chicago, IL 60602 Springfield, IL 627 56 www.cyberdriveillinois.com

The rules of the Secretary of State Department of Administrative Hearings require that certain documentation be presented at the time of a hearing to be considered for driving relief (Restricted Driving Permit (RDP) and/or Reinstatement). These documents are required regardless of when the DUI(s) occurred,

This form may be used as a guide to help you prepare for your upcoming hearing. It is important to be fully prepared for your hearing,as a continuance will not be granted if you do not have the proper documentation.Also note that you must have NO 1RAffiC TICKETS pending at the time of your hearing, unless the pending ticket is the only cause of the current loss of driving privileges.

GENERAL DOCUMENTATION REQUIREMENTS

You must submit an Alcohol/Drug EvaluaUon Uniform Report, completed subsequent to your mo.st recent DUI arrest by an agency licensed by the Division of Alcoholism and Substance Abuse (DASA).THIS REPORT MUST INCLUDE A RECITATION OF YOUR COMPLETE ALCOHOL/DRUG USE HISTORY, FROM FIRST USE TO PRESFNf USE. If your Uniform Report eval· uation or the last updated evaluation is more than six months old at the time of your hearing, you also must submit a current updated evaluation. An updated evaluation must be completed by the agency that completed your Alcohol/Drug Evaluation Uniform Report or by the agency that completed your treatment. An updated evaluation cannot be completed by the agency that completed the moderate (early intervention) counseling. A treatment provider may not conduct an update evaluation if it waives treatment, unless the provider verifies in writing that the petitioner's case file has been transferred.

The petitioner mnst provide a Treatment Needs Assessment whenever another Uniform Report is composed, regardless of whether the petitioner successfully completed intervention or treatment after the previous Uniform Report. The Treatment Needs Assessment shall be composed on the treatment provider's letterhead stationery. The Assessment must be signed and dated by the counselor responsible for the as.sessment or incorporated into the "Treatment Veri lication" form.

The Uniform Report will place you at a specific classification level.Depending on the classification level, you must comply with additional requirements as explained below. Completion of the DUI Risk Education Course must occur after the last DUI arrest date.

PLEASE REFER TO YOUR CLASSIFICATION LEVEL BELOW FOR COMPLETE REQUIREMENTS.

Minimal Risk • Must document successful completion of a DUI Risk Education Course.

Moderate Risk • Must document succes.sful completion of a DUl Risk Education Course. • Must document successful completion of an Early Intervention Program on the providing agency's letterhead indicating the

number of hours completed, dates of involvement, a summary of what was explored/addressed and the outcome of your involvement.

• Must document successful completion of any other substance abuse treatment recommended by a licensed evaluator or treatment provider.

(i Printed on recycled paper. Printed by authority of the State of Illinois. October 2017 - 6M - DAH IH 22.11

Significant Risk • Must document successful completion of a DUI Risk Education Course. • Must document on an original Secretary of State Treatment Verification form successful completion of any substance abuse

treatment recommended by a licensed evaluator or treatment provider, including: - Copy of the Individualized Treatment Plan. - Copy of Discharge Summary. - Copy of Continuing Care Plan. - Original ConUnuing Care Status Report.

• If no treatment provided, must submit a treatment waiver prepared on the providing agency's letterhead .

High Risk - (four or more DSM V Criteria) • Must document on an original Secretary of State Treatment Verification form successful completion of any substance abuse

treatment recommended by a licensed evaluator or treatment provider, including: - Copy of Individualized Treatment Plan. - Copy of Discharge Summary. - Copy of Continuing Care Plan. - Original Continuing Care Status Report.

• If no treatment provided, must submit a treatment waiver prepared on the providing agency's letterhead . • Must document complete abstinence from the use of all alcoholic beverages and controlled substances (drugs) by submit

ting at least three original letters, signed and dated within 45 days prior to your hearing, from individuals (friends, family, etc.) who can verify your abstinence from alcohol/drugs for at !east 12 months ii seeking reinstatement, but no les.s than six months for a Restricted Driving Permit. (Witness testimony is acceptable instead of letters.)

• Must document the establishment of a support/recovery program (Alcoholics Anonymous, church, etc.) by submitting: (Witness testimony is acceptable instead of letters.) - At least three original letters, signed and dated within 45 days prior to your hearing, from fellow members/participants, ver

ifying your active involvement in your support program. - If you have a support recovery program sponsor, must submit an original letter from your sponsor documenting your active

involvement in your support program, signed and dated within 45 days prior to your hearing.

High Risk - "Non-Dependent" (three DUI dispositions In last 10 years) • Must document on an original Secretary of State Treatment Verification form, successful completion of any substance abuse

treatment recommended by a licensed evaluator or treatment provider, including: - Copy of Individualized Treatment Plan. - Copy of Discharge Summary. - Copy of Continuing Care Plan. - Original Continuing Care Status Report.

• If no treatment provided , must submit a treatment waiver prepared on the providing agency's letterhead. • Must submit at least three original letters.signed and dated within 45 days prior to the hearing, from individuals (friends, fam

ily, etc.) who can verify either your alcohol/drug use pattern or abstinence for at least the last 12 months if seeking reinstatement, but no les.5 than six months for a Restricted Driving Permit. (Witness testimony is acceptable instead of letters.)

• Must submit an additional report from the treatment provider explaining why dependency was ruled out and the cause of your behavior that resulted in three or more DUI dispositions. This requirement cannot be waived.

Llfetime Revocation In addition to the list above: • Must document three years of uninterrupted abstinence. • If clas.5ified Level 2 significant risk or Level 3 high risk non-dependent, must show three years of uninterrupted abstinence

during any period of time after the most recent arrest for DUI.

Any questions regarding these requirements should be directed to an Informal Hearing Officer at a Secretary of State Driver Services facility or call 217-782-7065. lnformaUon also is available at www.cybenlriveillinols.com.

ILLINOIS PETITIONER ALCOHOUDRUG EVALUATION REPORT UPDATE

INSTRUCTIONS:

Office of the Secretary of State DEPARTMENT OF ADMINISTRATIVE HEARINGS

Additional !arms mar. be obtained at www.cyberdrive1llinois.com

An Alcohol/Drug Evaluation Report Update cannot be U8ed if the petitioner has been arrested for DUI since his/her Uniform Report/Investigative Report was completed (a new Uniform Report must be submitted).

Investigative Reports that did not recommend intervention normally do w;n reqnlre an npdated evaluation unless otherwise directed by the Secretary of State Department of Administrative Hearings.

If your agency only completed a Treatment Needs Assessment (fNA), early intervention or continuing care, your agency may not complete the Alcohol/Drug Evaluation Report Update (a new Uniform Report must be submitted).

This petitioner's case file transfered to this agency on __J __J __J from _____________ _

DYES □ NO

My agency completed a Uniform Report/Investigative Report on __j__J__J. □ YES □ NO

My agency provided primary alcohol/drug-related treatment to thls petitioner on __J __J __J. □ YES □ NO (Discharge Date)

If you answered yes to any of the last three statements, your agency may conduct the Alcohol/Drug Evaluation Update. This document shall report the nature and extent of the petitioner's use of alcohol and other drugs from the time period from his/her last evaluation to the present. Any new or additional recommended countermeasures must be reported and completed by the petitioner and documented for his/her application for driving relief. A petitioner is expected to complete the recommended countermeasures. If it is an ongoing countermeasure (such as support system attendance,abstinence, etc.), he/she is expected to follow those recommendations.

AU items contained in this form must be completed. The information provided should be typed, as illegible documents will delay the application process or result in the denial of petitioner's applic.ation. If more space is needed, attach additional sheets. Before completing this evaluation, review all previous evaluations, treatment summaries and the petitioner's last Denial Order from the Secretary of State (ii applicable).

NOTE: If not previously submitted, attach a copy of the Alcohol/Drug Evaluation Uniform Report, any subsequent Alcohol/Drug Evaluation Update and a copy of the petitioner's chronological alcohol and drug use history. If the Alcohol/Drug Evaluation Update is being completed by a treatment agency, a Comprehensive Discharge Summary also mU8t be submitted.

PERSONAL:

This Alcohol/Drug Evaluation Report Update form reports the nature and extent of the use of alcohol or drugs and the resulting recommendations for the following petitioner.

Name: (Last, First, Middle) Illinois Driver's License Number:

Address: (Street/City/State/ZIP)

Sex: Date of Birth: Home Telephone Number: Work Telephone Number:

□ M OF I I ( ) ( )

Beginning Date of Evaluation: _________ _ Completion Date of Evaluation: ________ _

Printed by authority of the State of Illinois. February 2016 - 1 - DAH IH 34.13

Instructions: All items under the following sections must be answered. !f more space is needed, attach additional sheets. When including any direct-quote state men ts, identify them with appropriate quotation marks. This evaluation covers the time between the petitioner's last evaluation through the completion date of this Alcohol/Drug Evaluation Update.

L ALCOHOL/DRUG USE HISTORY: Since the petitioner's last evaluation, report any periods of abstinence from alcohol, the !ength of each period of abstinence, and the reasons for becoming abstinent. If currently abstinent, report petitioner's abstinent date ________ _

What is your clinical impression on the petitioner's ability to maintain abstinence from alcohol?

Since the petitioner's last evaluation,has he/she become intoxicated while using alcohol? □ YES □ NO lf yes, how many times: ___ _

On the occasions the petitioner became intoxicated, did he/she typically consider himself/herself: □ slightly intoxicated, □ moderately intoxicated or □ heavily intoxicated?

On the occasions the petitioner became intoxicated, how much alcohol was typically consumed and over what time period?

2. Since the petitioner's last evaluation, report any periods of abstinence from substances other than alcohol. Identify the substance used, the length of each period of abstinence, and the reasons for becoming abstinent. If currently abstinent from all substances (excluding alcohol), report petitioner's abstinent date _____ _

What is your clinical impression on the petitioner's ability to maintain abstinence from illicit drug use?

Since the petitioner's last evaluation, has he/she become intoxicated while using substances other than alcohol? □ YES □ NO If yes, how many times: ____ _

On the occasions the petitioner became lntoxicated,did he/she typically consider himself/herself: □ slightly intoxicated, □ moderately intoxicated or □ heavily intoxicated?

On the occasions the petitioner became intoxicated, how much of the substance(s) were typically used and over what time period7

2

3. Since the petitioner's last evaluation, did he/she concurrently use alcohol and other substances? □ YES □ NO If yes, explain:

4. If the petitioner has used alcohol and/or drugs since his/her last evaluation, describe the petitioner's drinking and drug use pattern since the last evaluation, including frequency, type, amount, duration of said pattern, and report frequency of intoxications.

5. Since the petitioner's last evaluation, has he/she exhibited any impairments in significant life areas (social, legal, family.marital, physical , economic) , and/or has he/she exhibited any alcohol/drug-related problems, including but not limited to blackouts, increased tolerance, loss of control, withdrawal symptoms, increased alcohol or drug use, and using substances to selfmedicate chronic pain or symptoms of depression? □ YES □ NO Report frequency of each.

6. Report any current significant physical, medical, emotional/mental health or psychiatric problem(s) and participation in and/or completion of any treatment not previously reported or which has occurred since the last evaluation. A treatment discharge summary should be submitted for any treatment completed. A progress report should be submitted !or any treatment not completed . The petitioner will be informed whethera Medical Report form is required.

3

7. Is the petitioner taking any medication (prescription or over-the-counter) that when taken alone or in combination with alcohol or other drugs might impair driving ability? □ YF.S □ NO If yes, identify the medication and discuss any potential impairment. Petitioner will be informed whether a Medical Report Form is required.

Section 8 (a-d) is required for lhe first update evaluatlon only. 8. Review the information previously obtained regarding the petitioner's most recent DUI arrest or, if not revoked for DUI,

the most recent alcohol/drug-related arrest. This should include, at a minimum, the time and date of the arrest, reason for arrest, type and amount of alcohol or drugs consumed over what time period , petitioner's perception of the effect of the alcohol and/or drugs consumed.and any chemical test results.

a. Date of offense: _________ Type of offense: _____________________ _

b. Time of first drink: _____ Time of last drink: _____ Time breath or chemical test given: _____ _ Total consumption metabolism time (from first drink until test given): _________________ _

c. Does the blood-alcohol (BAC) reading of ________ correlate with the amount of alcohol consumed, total consumption metabolism time and petitioner's body weigh at that time? □ YES D NO Explain:

d. Type of substance used (other than alcohol) : ______________________ Amount of substance used: ________________ Time period substance was used: ________ _ Last time substance used before the alcohol- or drug-related arrest: __________________ _

9, Indicate any significant lifestyle changes, including employment, marital,social , family, economic, etc., jf applicable.

4

10. Identify current peer group and recreational activities, if applicable.

I I. Jf the petitioner is still using alcohol/drugs, what is his/her intent toward the future use of alcohol and/or drugs? Or, if the petitioner is abstinent, what is the petitioner's intent toward maintaining long-term abstinence?

12 . If the petitioner is "Alcohollc/Chemically Dependent," identify his/her support system, frequency of contacts with other members.duration of current attendance,petitioner's intent to continue with this support system.and the evaluator/treatment provider's impression as to whether this support system is sufficient to maintain long-term abstinence.

13. Report any alcohol/drug-related arrests not previously reported or which have occurred since the last evaluation, in any state, including felonies, misdemeanors, petty offenses and local ordinance violations since the petitioner's last evaluation, including the name of the offense(s), where and when it occurred, disposition of the offense(s) , and whether the petitioner is on probation or parole regarding the offense(s).

5

14. If you have been using the BAIID device how many, if any, BAilD violations have you had from the date of installation to date? _______________________________ ~---------

CORROBORATION: Interview with a Significant Other - May be a family member, frtend, employer, parentjguardlan, etc. The summary should include, but not be limited to, the following information: significant other's name, age and relationship to the petitioner; how long he/she has known the petitioner: how often he/she sees the petitioner, how long he/she has maintained his/her present level of contact with the petitioner, his/her perception of the petitioner's current alcohol or other drug use pattern and/or abstinence; and whether he/she can verify the duration of the petitioner's current alcohol use or other drug use and/or abstinence. Discuss how corroborative information lrom the interview either correlates or does not correlate with the information obtained from the DUI/alcohol/drug offender. This interview requirement cannot be waived and mUBt be conducted in every updated alcohol/drug evaluation completed.

RFSPONSE TO PRIOR DENIAL OF DRIVING RELIEF AND/OR ALL BAUD VIOLATIONS:

The evaluator/treabnent provider's response may be completed on agency letterhead and attached. a. The petitioner must submit to the evaluator/treatment provider his/her (a) last Order/Letter of Denial; (b) and/or Letter

of Rejection of Explanation from the BAIID Department reguarding a BAC violation incurred while driving on an RDP or MDDP: (c) and/or Order/Letter issuing a Restricted Driving Permit but containing unresolved issues to be addressed prior to reinstatement.The evaluator/treatment provider must effectively address the significant issues raised therin .Was this documentation submitted? □ YES □ NO Petitioner's failure to provide this information may result in the denial of the application for driving relief.

b. Summarize how each significant issue was effectively addressed and/or resolved.

c. Provide a dear and complete explanation of why this additional information either changes or does not change the petitioner's classification and/or alters your clinical impression.

6

d. Provide a clear and complete explanation as to whether this additional information warrants or does not warrant additional treatment hours. Additional treatment hours must be completed and properly documented before applying for driving relief.

CLASSIFICATION: This classification is based on the petitioner's alcohol/drug-related driving arrests, criminal arrests and symptoms of alcohol/drug abuse/dependency: Any reclassificatlon to a higher classtftcation requires referral to a licensed treatment provider to assess the petitioner's current need for treatment.

CURRENT CLASSIF]CATIQN:

0 MINIMAL RISK D MODERATE RISK D SIGNIFICANT RISK D HIGH RISK NON-DEPENDENT

PREVIOUS CLASSIFlCATION:

□ MINIMAL RISK D MODERATE RISK D SIGNIFICANT RISK D HIGH RISK NON-DEPENDENT

(3 DUI dlsposltlons in a IO year period from the date of the most recent DUI arrest; further assessment required)

D HIGH RISK CHEMICAL DEPENDENCY

(four or more DSM Y symptoms)

□ ACTIVE 0 IN REMISSION

□ HIGH RISK CHEMICAL DEPENDENCY

D ACTIVE □ IN REMISSION

Provide your rationale for selecting this classification, including an explanation if the classification appears to conflict with those symptoms or general indicators you have identified and described in this report.

7

1. RECOMMENDATIONS: Report previous recommendations and when they were successfully completed.

2. Report any new or additional recommendations and provide a rationale for such recommendations. If "d" was completed under PRIOR DENIAL OF DRIVING RFLIEF, no response is necessary. Additional treatment hours must be completed and properly documented before applying for driving relief.

EVALUATOR VERIFlCATION (required):

I certify that I have accurately reported the data collected and required in order to complete the evaluation update.

Provider's Name: (type or print)

Provider\ Signature: Date:

Provider's Title: Telephone Number:

Program Name: Accreditation/License Number:

Address: (Street/City/State/ZIP)

This evaluation update must be signed, dated and be no more than m months old from the Completion Date of Evaluation found on page I when received by the Secretary of State's office.

PETITIONER VERIFlCATION:

Must be verified 1n the presence of the evaluator/treabnent provider.

The information I have provided for this Alcohol/Drug Evaluation Report Update is true and correct. I have read the information contained in this report and all the recommendations have been explained to me.

Petitioner's Signature: ___________________________ Date; ________ _

8

~ OFFICE OF THE SECRITARV OF STATE

. DRIVER SERVICES DEPARTMENT Medical Report

DRIVER ANALYSIS DIVISION 2701 S. DIRKSEN PARKWAY

SPRING FIELD, IL 62 723 217-7 82-7246

www.cyberdrivei llinois.rnm

Please see guidelines at www.cyberdriveillinois.com, search for MedicaVVision Conditions for completion of form.

SECTION I - To be completed by driver. (Please print or type.)

Name: ___________________ _ Driver's License Number: ____________ _ Last First Middle

Street Address: ________________ Date of Birth: ________ _ Gender: □ Male □ Female Month Day Year

City: ______________________________ ZIP Code: ________ _

Agreement/Release of Infom,ation I agree to remain under the care of my physician and _follow the treatment exactly as prescribed. I hereby authorize and request my physician to release information regarding my medical condition to the Illinois Secretary of State, and to report any change in the status of my condition that would impair my ability to safely operate a motor vehicle. I understand that _foi/ure to abide by the condib'ons set forth in this agreement are grounds for the Secretory of State to deny or cancel my driving privileges. This report shall remain valid for three months (90 days).

Sigm1ture of Individual Date of Signature

SECTION II MEDICAL HEALTH - To be completed by MD/DO and/or medical professional (NP/PA).

DATE OF COMPLETION OF MEDICAL HEALTH SEmON II: -------------

1. Required: In your professional opinion, is this individual MEDICALLY FIT to safely operate a motor vehicle? .... I Y_E_S_□ ___ N_O_□~I 2. Conditions: Yes or No required for each condition listed.

(a) Cardiovascular YES □ NO □ (provide condition) __________________ _ (b) Neurological YES □ NO □ (provide condition) __________________ _ (c) Musculoskeletal YES □ NO D (provide condition) __________________ _ (d) Respiratory YES □ NO □ (provide condition) __________________ _ (e) Seizure YES □ NO □ (provide condition) __________________ _

(f) Diabetes YES □ NO □ (g) Dizzy/Fainting Spell YES □ NO □ (h) Alcohol/Drug Abuse YES □ NO □ (i) Other Medical Condition { s) (provide condition) __________________ _

*For mental health disorders, please refer to Section III-Mental Health.

3. List all current medications. (If medications are listed, a condition must be disclosed above in Question #2.) ____ _

4. □ No medications prescribed.

5. Required: Current Status of Condition: {A) Controlled □ (8) Not Controlled: will not affect driving □ (C) Not Controlled: may affect driving □ (If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e., test results, lab values.)

{continued on back)

Printed by authority of the State of Illinois. Januar}' 2019 - 27.5M - OSD DC-163.8

PATIENrs NAME:------------------

6. Required: In the past six months, has the driver's ability to safely operate a motor vehicle been impaired (due to any reason) or has driver experienced an attack of unconsciousness? YES O NO □ Date of Attack: ______ _

(If YES, you must provide details, which may include pertinent clinical information.)

7. Date of last impaired ability to safely operate a motor vehicle or attack of unconsciousness. Date: _______ _ (You must provide details, which may include pertinent clinical information.)

SECTION III MENTAL HEALTH - To be completed ONLY if driver has a Mental Health Disorder marked uYES" by MD/DO and/or medical professional (NP/PA).

Mental Health Disorder: YES □ NO □

DATE OF COMPLETION OF MENTAL HEALTH SECTION 111: ____________ _

1. Required: In your professional opinion, is this individual MENTALLY FIT to safely operate a motor vehicle?!,_ Y_E_S_□ ___ NO_□__, 2. Mental Health Disorder Diagnosis/Condition(s): __________________________ _

3. List all current mental health medications. (If medications are listed, a condition must be disclosed above in Question #2.)

4. □ No medications prescribed.

5. (A) Controlled □ (B) Not Controlled: will not affed driving O (() Not Controlled: may affect driving D (If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e., test results, lab values.)

SECTION IV - Additional information, special restrictions, etc.

SECTION V - MD/DO and/or medical professional (NP/PA) - Failure to provide license information will result in return of form to the driver.

(Unacceptable Signatures: Chiropractors, Podiatrists, Residents, Fellows, Interns, RN's, LPN's, Co-signatures)

MEDICAL:

Provider Name (PRINTED)

Professional License Number/State License Issued

Provider's SIGNATURE - Date of Completion

MENTAL:

Provider Name (PRINTED)

Professional License Number/State License Issued

Medical Provider's Address (PRINTED/STAMPED)

( Telephone Number

□ MD □ DO □ NP O PA Provider's Specialty

Medical Provider's Address (PRINTED/STAMPED)

Telephone Number

Provider's SIGNATURE - Date of Completion □ MD □ DO □ NP □ PA Provider's Specialty

PLEASE MAINTAIN A COPY FOR YOUR RECORDS.

VERIFICATION OF HEARING DOCUMENTS

Office of the Secretary of State DEPARTMENT OF ADMINISTRATIVE HEARINGS

Additional forms may be obtained at www.cyberdriveillinois.com

A DUI service provider should use this form to verify that a document(s) is a true and correct copy (identical reproduction) of the original, or to provide reasons why it is unable to provide the original of a document(s).

Client/Petitioner's Name Illinois Driver's License Number

I. □ The following document(s) is a true and correct/identical copy of the original(s) as verified by the service provider whose signature appears on the following page.

Check Appropriate Docwnent(s): □ Alcohol/Drug Evaluation Uniform Report

□ Addendum to Uniform Report

□ DUI Risk Education Certificate of Completion

□ Dischargeffransfer Authorization and Treatment Summary Including Individualized Treatment Plan

□ Secretary of State Treatment Verification Form

□ Secretary of State Alcohol/Drug Evaluation Uniform Report Update(s)

□ Other (specify): _____________ _

Date of Document

2. □ The original of the following document(s) is no longer available for the following reason(s) as verified by the service provider whose signature appears on the following page.

Check Appropriate Document(s): □ Alcohol/Drug Evaluation Uniform Report

□ Addendum to Uniform Report

□ DUI Risk Education Certificate of Completion

□ Discharge/fransfer Authorization and Treatment Summary Including Individualized Treatment Plan

□ Secretary of State Treatment Verification Form

□ Secretary of State Alcohol/Drug Evaluation Uniform Report Update(s)

□ Other(specify): _____________ _

Check Appropriate Reason:

□ The document has been destroyed.

□ The client informs this agency that he/she lost the original document.

Date of Document

□ The agency that composed the document is no longer in operation and did not transfer its records to this agency when it ceased operation.

□ Other (explain):

Service Provider's Name and Title (type or print) Date

Service Provider's Signature Accreditation/License Number

Printed by authority of the State of Illinois. August 2009 -1 - DAH H 82

IL DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation.

All questions in this questionnaire should be answered. Do not skip any questions. Your cooperation is appreciated.

The term "substance use" refers to alcohol and drugs.

Anticipate approximately 20 ± minutes to complete this questionnaire.

You may begin.

Section 1 The statements in this section are to be answered true or false. If a statement is true, put an X under T for True on your answer sheet. If a statement is false, put an X under F for False on your answer sheet.

1. There have been times when I have been irritated and frustrated by other drivers.

2. I am concerned about my drinking.

3. I am an impatient person and usually drive fast.

4. I have used drugs more than I should.

5. There are times when I get very angry.

6. My drinking has caused serious family and social problems for me.

7. I am quick tempered and need to learn how to control it.

8. There have been times when I have felt guilty about my use of drugs.

9. I often drink more or use more drugs than I intended.

10. There are times when I really worry about myself and my happiness.

11. There are times when I feel guilty about my drinking.

12. I can be easily annoyed or angered while driving.

13. I am concerned about my drug use.

14. I have used my cell phone while driving.

15. My drinking is more than just a little or minor problem.

16. When I get frustrated and annoyed at another driver I tend to "fly off the handle" and cur.se or swear at them.

17. A family member has told me I should get help for my drug use.

18. I spend a lot of time using alcohol and/or drugs and recovering from their effects.

19. There have been times when I have driven after drinking.

20. I attend Alcoholics Anonymous (AA) meetings because of my drinking.

21. Even though I wasn't caught, I have made mistakes while driving that were my fault.

22. I have been treated for a drug problem.

23. I know I shouldn't, but there have been times when I have been jealous of others' success.

24. Once I begin drinking, it often seems as ifl cannot stop.

25. I get angry quickly.

26. My repeated substance (alcohol/drug) use has resulted in my failing to fulfill important duties and responsibilities at home, school or work.

27 . I get upset when others criticize or blame me.

28. I have had two or more memory losses (blackouts) after drinking heavily.

29. There are times when I get really frustrated and angry.

30. I admit I am often an aggressive driver.

31. I have had a drug abuse problem in the past. 48. My use of drugs has threatened my happiness and success in life.

32. I don't consider myself a fast or aggressive driver, but at some point I do exceed the speed 49. Even though I am aware of the hannful effects limit almost every time I drive. of repeated substance use, I continue to drink

33. I continue to drink despite family arguments and/or use non-prescription drugs.

about my drinking. 50. Sometimes I get angry and upset at myself

34. I regret some of the things I have said or done 51. I have had to use much more alcohol and/or when I was angry or mad. drugs to get the same effect I used to.

35. To be honest, I am a fast and aggressive 52. I have missed school or work because of my

driver, drinking.

36. There are times when I am concerned that others may think badly ofme. 53. I have lied about my use of drugs- either

saying r"use less than I really do, or hiding the 37. I go to Narcotics Anonymous (NA) or fact that I use drugs at all.

Cocaine Anonymous (CA) meetings because of my drug use. 54. I am a careless, inattentive or indifferent

driver. 38. I do not always tell the whole truth when

asked about my personal life. 55. People tel! me I lose control over little

39. I contjnue my substance (alcohol/drugs) use problems and minor frustrations.

despite the recurrent social and interpersonal 56. I have been treated for a drinking problem. problems this causes.

57. I have admitted to a close family mernher that 40. There are times when I am really down, I have a drug problem.

depressed and discouraged.

I am a recovering alcoholic. 58. I often take substances (alcohol/drugs) in

41. larger amounts or over a longer period than I

42. When I am angry or mad I become verbally intended.

abusive and shout or swear a lot. 59. I use and sometimes abuse drugs.

43. It bothers me when I am overlooked or ignored by people I know. 60. I send and receive text messages while

driving. 44. I have given up or reduced important social,

occupational or recreational activities because 61. I have done tirings when angry or mad that I

ofmy substance (alcohol/drug) use or abuse. later regretted.

45. There are times when I am very unhappy. 62. I am in counseling or treatment for my

46. I have admitted to a family member that I drinking problem,

have a drinking problem. 63. To be honest, I drive too fast.

47. Two or more of the following apply to me 64. I continue to use drugs despite family (answer true or false on your answer sheet): arguments about my drug use.

a. I have driven without proper insurance. b. My driver's license has been suspended 65. Almost all of my normal daily activities are

or revoked. associated with ( or affected by) my substance C, I use my cell phone while driving. use and abuse. d. I have had three or more speeding

tickets in the last ten years. 66. Drinking has interfered with my happiness and

e. I have caused two or more at-fault success in life.

accidents.

67. I have a drug problem.

68. There are times when I really won-y about myself and my future.

69. Within the last year I have had persistent cravings and strong urges for my alcohol and/or drug use.

70. Because of my drug use I have given up or quit social functions, work and/or recreational activities.

71. I continue using substances (alcohol/drugs)_ even though I know they cause physical and psychological problems for me.

72. I have a drinking problem.

73. There have been times when I knew I should not drive - but did.

Section 2 1

The statements in this section describe you or your situation. Put an X under the number (1, 2, 3 or 4) on your answer sheet that is most accurate for you.

7 4. Rate your "driving" on a ten point scale. One represents a "poor'' driver-rating whereas ten represents a "good" driver-roting I rate myself as:

1. A poor (rate 1 or 2) driver. 2. An adequate (rate 3, 4 or 5) driver. 3. A below average (rate 6, 7 or 8) driver. 4. A good (rate 9 or 10) driver.

75. My drinking is: 1. A serious problem. 2. A moderate problem. 3. A mild problem. 4. Not a problem.

76. My drug use is: 1. A serious problem. 2. A moderate problem. 3. A mild problem. 4. Not a problem.

7 7. I have tried but I cannot: 1. Reduce, cut down or control my use of

alcohol and/or drugs. 2. Stop using alcohol and/or drugs. 3. Both 1 and 2. 4. None of the above.

78. Rate your drinking on a ten point scale. One represents "no problem," whereas ten represents a "severe drinking problem." I rate my drinking as:

1. No problem (rate 1 or 2). 2. Mild alcohol use (rate 3, 4 or 5). 3. A drinking problem (rate 6, 7 or 8). 4. A severe drinking problem (rate 9 or 10).

79. Rate your drug use on a ten point scale. One represents "no drug use problem," whereas ten represents a "severe drug abuse" problem. I rate my drug use as:

1. No drug use problem (rate 1 or 2). 2. Mild drug use problem (rate 3, 4 or 5). 3. A drug abuse problem (rate 6, 7 or 8). 4. A severe drug abuse problem (rate 9 or

10).

80. Within the last year I have had intense urges or cravings for my substance of choice:

1. In settings where I had used the substance.

2. Randomly, at different times and places.

3. Both 1 and 2. 4. None of the above.

81. How would you describe your desire to get alcohol treatment or help?

1. I want help. 2. I may need help. 3. Maybe, not sure. 4. No need.

82. My repeated substance (alcohol/drug) use has resulted in:

1. Absences or poor performance in school or work due to alcohol and/or drug use.

2. Neglecting my household duties or responsibilities.


83. I have continued alcohol and/or drug use despite persistent and recurrent:

1. Social and/or interpersonal problems 2. Arguments or fights with my family or

significant other about my substance use. 3, Both 1 and 2. 4. None of the above.

84. Recovering means have a substance (alcohol/ drug) abuse problem, but not drinking or using drugs anymore. I am a recovering:

1. Alcoholic. 2. Drug abuser. 3. Both 1 and 2. 4. None of the above.

85. I have repeatedly used alcohol or drugs: 1. In physically hazardous or dangerous

situations like swimming, boating, driving or skiing.

2. Before driving or operating machinery. 3. Both 1 and 2. 4. None of the above.

86. How would you describe your desire to get drug treatment or help?

1. I want help. 2. I may need help. 3. Maybe, not sure. 4. No need.

I

87. I have noticed within the last year: 1. I use a lot more alcohol and/or drugs to

get intoxicated or high. 2. I do not get intoxicated or high when I

use the same amount of alcohol or drugs that I used to use.


8 8. I have had withdrawal symptoms like trouble sleeping, tremors, sweating, nausea, vomiting, headaches, etc.:

1. After reducing my alcohol/drug use. 2. When I stopped my alcohol/drug use. 3. Both 1 and 2. 4. None of the above.

89. How many different drug treatment programs have you been enrolled in?

1. One. 2. Two or three. 3. Four or more. 4. None.

Section 3 Rate each statement as it applies to you now. Put an x· on your answer sheet under the number that you select for your answer. Use the following rating scale.

1. Rare or Never 3. Often 2. Sometimes 4. Very Often or Always

90. Positive Attitude / Outlook

91. Anxious/ Worried/ Fearful

92. Satisfied with Self/ Like Self

93. Nervous/ Unable to Relax

94. Impulsive/ Spontaneous

95. Financially Stable/ Responsible

96. Dissatisfied with Life

97. Able to Handle Life's Problems

98. Insomnia/ Trouble Sleeping

99. Careful/ Considerate Driver

100. Enthusiastic/ Involved in Life

1 01. Fatigued / Tired / Sluggish

102. Angry I Hostile with Others

103. Work/ Job Satisfaction

104. Tension/ Stress / Pressure

105. Trust My Own Judgment

106. Depressed / Discouraged

107. Rebellious/ Unruly/ Defiant

108. Content with Life/ Satisfied

109. Lonely/ Unhappy

110. Careless / Inconsiderate Driver

111. Patient/ Tolerant / Understanding

112. Emotionally Upset/ Crying

113. Express My Feelings Comfortably

When finished tum in your questionnaire and answer sheet.

Thank you for your cooperation.

IL DRI-2 Answer Sheet

Accurately Complete the Followin2 Information

Name: --------First Name Middle Initie.1 Last Name

Age: __ Date of Birth: / / Month Day Year

Sex: MD, FD Education (Highest Grade Completed): __ _

Ethnicity (Race): ________________ _

Marital Status: -------------------Single, Manied, Divorced, Seplll1lted, Widowed

Last Four Digits of Your SSN: Today's Date: I I Month Day Year

INSTRUGl'iON.S: It th~ ~wpds nori.e, p~l iii J' z~~. if th~. iterii do~s not -~pplytcpou pu(~ ~ '"1'-T'::?.._ if t!t~:BA9 ·1~JeN5e~:e~tei;, ''R.0-?. If there:js no BAG ehter-''N'1 otherwise,,eiiter anattairiM three digiiBAC level htu:nber::., ·_

,., • 'I -:-.. !, ·'.. ~- •:•~· .:•,;-:.•, ~,.. -~·•-: ... :•.·,·,· : .: ~ •.. ..,,_ . -.- ' ,. •

1. Date of your present DUI/DWI: ___ / ___ / __ _ 2. Do you have other or additional DUI/DWI offenses

pending? ........................................................................ Y_ N_

3. Primary/ underlying reason for your present DUL'DWI (select one):

Alcohol O Marijuana (pot) D Drugs □ Substance abuse □ Zero Tolerance D Impaired due to other substances D

4. Blood Alcohol Content (BAC) level at time of DWI arrest: •

5. Did you refuse a breath/blood test? ................................. Y_ N_

6. Number of DUI/DWI arrests in your lifetime (include current arrest): ..................................................................................... __ _

7. Is your driver's license suspended orrevoked? ............. Y_ N

8. Was your current arrest reduced to careless or reckless driving? .......................................................................... Y_ N

9. Number of alcohol-related (not DUJ/DWI) arrests in your lifetime: .................................................................................. . ---

10. Number of drug-related (not DUI/DWI) arrests in your lifetime: .................................................................................. __ _

11. Number of at-fault motor vehicle accidents in your lifetime:. ---12. Total number of traffic violations (tickets) in your lifetime: .

Section 1 If a statement is True, put an X under T for True. If a statement is False, put an X under F for False.

T F T F 1. 29.

2. 30.

3, 31.

4. 32.

5. 33.

6. 34,

7. 35.

8. 36.

9. 37.

10. 38.

11. 39.

12. 40.

13. 41.

14. 42.

15. 43.

16. 44.

17. 45.

18. 46.

19. 47.

20. 48.

21. 49.

22. 50.

23. 51.

24. 52.

25. 53.

26. 54.

27. 55.

28. 56.

Section 1, continued Section 3 T F T F Put an X under the number (1, 2, 3 or 4) that

57. 65. describes you best. Use the following rating

58. 66. scale to select your answers.

1 = Rare or Never 3= Often 59. 67. 2= Sometimes 4= Very Often or Always

60. 68. 1 2 3 4

61. 69. 90. --

62. 70. 91.

63. 92. --71. 93.

64. 72. --

94. 73.

95. -- --96. --

Section 2 97. --Put an X under the number (1, 2, 3 or 4) 98. that is accurate for you.

1 2 3 4 99.

74. 100. ----

75. 101, -- --

--102.

76. -- 103.

77. -- 104. -- -- -- --

78. 105. ---- --79.

106. ---- --

107. -- --80. -- -- -- 108. --81. 109. -- -- --82. 110. -- --

83. 111. -- --

-- -- -- --112. --

84. -- -- -- 113. -- --85. -- -- -- --

86. -- --

87. When finished turn in your questionnaire and answer -- -- -- -- sheet.

88. -- --

89. Thank you for your cooperation.

--v.32.614

r 5 - Generate Report

Name: Age: 25 Sex: Male Date Of Birth: 08/26/2017 Race: Caucasian Marital Status: Single

Illinois Driver Risk lnventory-2

CONFIDENTIAL REPORT

Last 4 Digits of SSN: 0000 Education: Tech./Business School DRl-2 Date: 8/23/2017

Driver Risk lnventory-2 (DRl-2) results are confidential and should be considered working hypotheses. No decision should be based solely upon DRl-2 results. The DRl-2 is to be used in conjunction with experienced staff judgment.

Mandatory Minimum DUI Risk Higt, {Severe Problem) Risk Mr. Illinois Mandatory Minimum DUI Risk Classification is in the High (Severe Problem) Risk range. High risk is characterized by the following: four or more DSM-5 Substance Use Disorder symptoms (regardless of his driving record), and/or within the last ten years any combination of two or more prior DUI convictions, court ordered DUI supervisions, prior statutory summary suspensions, or prior reckless driving convictions reduced from DUI (resulting from separate incidents). In summary, Mr. , Illinois Mandatory Minimum DUI risk range is in the High (Severe Problem) Risk range.

Different Measures Illinois' Mandatory Minimum DUI Risk Classification uses court-related data and DSM-5 Substance Use Disorder criteria to classify DUI risk. While the Substance Use Disorder scale consists of admissions to eleven DSM-5 questions, the Alcohol and Drug Scales focus on client opinions regarding their drinking and drug use. That said, different measures may produce different results. Illinois mandatory minimums take precedence.

Illinois Driver Risk lnventory-2 (DRl-2) Profile

+-------------------+--------------+---------+----+ I LOW RISK I MEDIUM I PROBLEM I MAXI

Truthfulness 25 ■■■■■■■■■■■■ .. . ..... I .••••••.....• -1 •••••••.• j •••• I +-------------------+--------------+---------+----+ 0 40 70 90 100

Truthfulness Scale: LOW ATTAINED SCORE: 25% Mr. . Truthfulness Scale score is in the low risk (zero to 39th percentile) range. Low risk scorers are generally sincere, candid and plain spoken. Client (DUI offender) truthfulness has been linked to positive counseling and treatment outcomes (Simpson, 2004). In contrast, denial (problem minimization or refutation) has been linked to negative treatment outcomes (Marshall, et al, 2001). References or citations are available on www.driveMisk-inventory.com and DRl-2 truthfulness research is presented on www.bds-research.com . Assessors can rely upon Mr. answers to Driver Risk lnventory-2 (DRl-2) questions because he was honest and truthful while completing the DRl-2.

100th 9bth ..... ····· ··· ··········· ··· ·· ·· ········ ··········· ···· •9·2%■·· •· ·····-····•94%• ··········· ·······••9 5%•· ······································· •············ ········· ·· ·· ·· ·············· ···· ·· ·•se·v·e·r·e········ ····· · ····· ················ ........ .. .............. .. ......................................... .. .......... ••·•••··· ·· ·············· ··••••• ...... ......................... ........ ............ ...... .. ......................................... P.r·ohl·e·m .......... ..... . 70th I ••••• ■■■■■ ■■■■■ · ............. r ....... · ............................................................. ··· ......... ........... ........... "•i68%• · ··· ... ......... i"i:i6%■·- .. -· .............. f;fo'd"ifr"a"fe"""···· ..

I ••••• ••••• ••••• ••••• ••••• . 49.~.~ .... + .. .. ........ .. .. ................ .......... .......... :.::·:·:··· .. ··· .... ... .. ::·::: .. .. ............... ::::: .............. .... ::::: ............ ........ ::::·: ··· ......... ..... Low ... R i sk ......... .

I ■25%■ •••• ••••• ••••• ••••• •-•• I ••••• ••••• ••••• ••••• ••••• ••••• 0 '-••·••---••--·-----••·•·--···••--•····--·•····------Truthfulness Alcohol Drug Substance Driver Stress

Scale Use Risk Mgmt.

•: //www.online-testing.com/Illinois/ILD RI2 _ DS M5/GenerateReport. aspx

Page 1 ,

9/7/21

15 - Generate Report

NAME: Mr. -2-

Page 2 (

IL DRl-2 REPORT

ADDITIONAL INFORMATION PROVIDED BY CLIENT

Date of Present DUI Arrest 09/02/2016

Reason for Arrest .............. .. ....... ............. ...... ..................... ... Drugs Additional DUI Offenses Pending? .......... ................. No

BAC at Time of Current Arrest ........... ....................... NIA Refused Breath/Blood Test in Current DUI? No

Lifetime DUI Arrests 1

Driver's License Suspended/Revoked? ............... ..... Yes Arrest Reduced to Careless/Reckless Driving? No

Lifetime alcohol-related (not DUI) arrests ........ .. ........... O

Lifetime drug-related (not DUI) arrests....................... 4

Lifetime At-Fault Motor Vehicle Accidents 4

Lifetime Traffic Violations (Tickets) ........ .................... .. ........ .. 3

Scale Score Paragraphs

All seven Illinois DRl-2 scale-related paragraphs explain when problems exist and what each attained scale score means. It should be understood that the Illinois Mandatory Minimum DUI risk range has priority and takes precedence. Nevertheless, when problems exist, risk-related recommendations are offered.

Substance Use Disorder: SEVERE The DSM-5 postulates eleven substance use severity criterion . Substance use severity is then determined by the number of the eleven substance use severity criteria that are admitted to. Mr.

admits to six or more of the eleven severity criteria, which meets the DSM-5 severe substance use classification. Admitting to six or more of the eleven criteria is the highest or most severe classification . This DSM-5 codification is equivalent to a Driver Risk lnventory-2 (DRl-2) severe problem (90 to 100th percentile) classification. By DSM-5 substance use severity standards Mr. , has a severe substance abuse problem. Severe problems require intensive outpatient or inpatient treatment.

Alcohol Scale: SEVERE ATTAINED SCORE: 92% Mr. Alcohol Scale score is in the severe problem (90 to 100th percentile) range. Mr. has a severe drinking problem. Recommendations: consideration should be given to either "intensive outpatient treatment" or "partial hospitalization." This level of care allows patients to live in their home (real world) while receiving treatment. In other words, patients can sustain relationships, employment and maintain their income. Should Mr. , relapse his optimum level of care would likely increase to "residential/inpatient" treatment. Self-help or mutualhelp group meetings would likely augment, but should not replace treatment.

Drug Scale: SEVERE ATTAINED SCORE: 94% Mr. , Drug Scale score is in the severe problem (90 to 100th percentile) range. Consideration might be given to either "intensive outpatient treatment" or "partial hospitalization." These levels of care allow patients to continue to live at home and keep their jobs while receiving chemical dependency treatment. This helps patients sustain relationships and employment while in treatment. Self-help meetings are generally available on-site to augment, not replace, treatment. An interdisciplinary treatment team would be advantageous when treating co-occurring disorders and "imminent danger'' cases. Should Mr. relapse his optimum level of care would likely increase.

Driver Risk: MODERATE ATTAINED SCORE: 68% Mr. , Driver Risk Scale score is in the moderate risk (40 to 69th percentile) range. Some indicators of inattentive driving are present, but an established pattern of irresponsible driving is not present. Mr. may only be a driving risk after using alcohol (beer, wine or liquor) or drugs (prescription and/or nonprescription). Prudent assessors will check out the other Driver Risk lnventory-2 (ORl-2) scales that can directly contribute to Mr. , driving risk, e.g., Truthfulness Scale, Alcohol Scale, Drug Scale, Substance Use Scale and the Stress Management Scale. Any elevated (70th percentile and higher) scale scores would contribute to driver risk. On its own merits Mr. ; Driver Risk Scale indicates he is a safe driver.

, ://www.online-testing.com/Illinois/ILD Rl2 _ DSMS /G enerateReport. aspx 9/7/21

15 - Generate Report

NAME: Mr. -3-

Page 3 <

IL DRl-2 REPORT

Stress Management Scale: MODERATE ATTAINED SCORE: 66% Mr. Stress Management Scale score is in the moderate (40 to 69th percentile) range. Stress management issues are becoming apparent. If left unattended these potential issues or concerns could worsen. Recommendations: a "brief intervention" might be considered. Brief interventions range from 15 to 30 minutes of direct face-to-face staff-client (offender) discussion, they can be a valuable intervention for clients with early stage stress-related problems. There are also many good self-help stress management books that help readers recognize their stress, reframe it and positively manage it. They also discuss stress reduction techniques like relaxing body parts, deep breathing exercises, meditation, etc. Another alternative is enrollment in a stress management class. Stress-related issues are emerging.

Significant Items. The following self-report responses represent areas that may help in understanding the respondent's situation and status.

Alcohol

6. Drinking caused serious problems. 11 . Feels guilty about drinking. 46. Admits has drinking problem. 56. Been treated for drinking.

*Additional Items: #72 , 9, 20, 28, 41, 62 and 84.

Substance Use Disorder

9. Often drinks more than intended. 26. Fail to fulfill important duties. 44. Gave up important activities. 71. Continue using despite knowing causes problems.

*Additional Items: #80 , 83 and 88.

Drug

8. Guilt about using drugs. 22. Been treated for drug problem. 31. Had drug abuse problem. 53. Has lied about drug use.

*Additional Items: #57 , 59, 67, 76, 79, 17, 37, 48, 70 and 89.

Driver Risk

14. Use cell phone while driving. 47 . Admits to 2 or more scale items.

* Only two significant items were selected.

Comments/Recommendations:, ________________________ _

Use back of this page, if necessary

STAFF MEMBER SIGNATURE DATE

IL DRl-2 RESPONSES

1 - 50 TFFTFTFTTT TFFTFFTFTT TTTFFTTTFF TFFTFTTFFT TFI II I I IFT 51 - 100 FFTFFTTFTF TTFFFTTTFT TTT4324242 3433434233 2342213233

101 - 113 2133321321 423

Copyright© 2016 Behavior Data Systems, Ltd. All Rights Reserved

) :/ /www, online-testing. com/Illinois/ILD RI2 _ D SM5/GenerateReport.aspx 9/7/21

Adult Substance Use and Driving Survey {Revised for Illinois) ~ ASUDS~RI

Instructions

Answer each question in this booklet as to how you see yourself. Choose the answer that best fits you. Give careful thought to your answers. It is important that you answer each question as accurately as you can.

Please give an answer to every question.

Mark only one answer for each question.

Please read the instructions that are provided for the different parts of this survey. In some parts, you are asked to give answers as to how they apply to your life time and then as to how they apply during the last 12 months that you have been in the community.

Carefully read each question and each possible answer before making your choice.

You are asked to mark your answers on this survey booklet.

If you have any questions, ask the person who is giving you this survey.

Your answers will be treated as confidential according to the laws of your state and the Federal confidentiality laws and within the guidelines of the consent you have provided to your agency for the release of confidential information about you. Before you start to answer the questions, please complete the following information .. D D

Name: T C'::='t)b'f -r'2QuBLE Date: \0 \ oz..\ 01-I Agency: bk.

Date of Birth:

Ethnic Group:

Marital Status:

\2 { ~\ tct8(p Age: w 1~Male □ Female

□ African American ~ Anglo-American V\/hite □ Asian American □ Hispanic American D Native American

fg1' Never Married □ Married □ Separated □ Divorced

Copyright (c) 2005 K.W. Wanberg and D.S. Timken All rights reserved

Center for Addictions Research and Evaluation - CARE

D Remarried □ VVidowed

No part of this booklet may be reproduced in any form of printing or by any other means without permission of the authors and the Center for Addictions Research and Evaluation - CARE (IL0105)

2

ADULT SUBSTANCE USE AND DRIVING SURVEY-REVISED FOR ILLINOIS (ASUDS-RI)

Please circle the letter by the answer to each question that best fits how you see yourself

1. Did you drink" (alcohol) to have fun or to be happy? a. No. b. Sometimes.

/c.))ftan. ~ Very often.

2. Did you drink to relax socially? a. No. b . Sometimes.

~flen. d. Very often.

3. Did you take a drink or two to relieve youffielf of worries? a. Never.

~ometimes. c. Often. d. Very often.

4. Have you had a bad headache because of having too much to drink? a. No. b. One or two times , c. Three or four times.

@:;F"ive or more times.

5. How many times have you been drunk? a. Never. b. Once or twice. c. Several times.

~any times.

6. Have you been "half with it" at work or called in sick because you had too much to drink? a. No.

@onetime. c. Two or three times. d. Four or more times.

7. Have you ever been unable to think or concentrate clearly after drinking? a. No. b. One time. c. Two or three times.

@our or more times.

8. Did you drink when feeling down and depressed?

A Never. Uv Sometimes.

c. Often. d. Very oft.en.

• Drink (or drinking) refers lo the use of alcoholic beverages.

9. Did you ever drive an automobile knowing you had too much to drink? a. No, b. Onetime.

(§y. few times. d. Many times.

10. Have you ever passed out as a result of drinking? a. No. b. Once.

@Two or three times. d. Four or five times or more.

11. Have you ever felt down in the dumps after drinking? a. No. b. One time.

@. couple of times. d. Several times.

12. Have you ever been unable to recall what you did when you Ill/ere drinking? a. No. b. One time.

@Two times. d. Three or more times.

13. Did you drink 1o relieve stress? a. No.

@sometimes. c. Often. d. Very often .

14. I exceed the speed limit if road conditions are safe. a. Never.

@eldom. c. Often. d. Very often.

1 l.~S I

15. I have found mysetf driving fast without realizing it.

.,.i;..._Never. ~e!dom.

c. Often. d. Very often.

16. When other drivers do stupid things, I ~e my temper. (_vNever.

b. Seldom. c. Often. d. Very often .

3

17. I drive fast and take my chances of getting caught.

_A.Never. ~Sometimes.


18. High speed driving gives me a sense of ower.

ever. Very seldom.

c. Sometimes. d. Often.

19. I have taken a risk when driving just because I felt like it.

@Never. b. Very seldom. c. Sometimes. d. Often.

20. I swear out loud or cuss under my breath at other drivers. a. Never.

@seldom. c. Often. d. Very often .

21 . I have outrun other drivers. @lever.

b. Very seldom. c. Sometimes. d. Often.

22. I pass other drivers when not in a hurry. a. Never.

@seldom. c. Often. d. Very often.

23. I am a driver who likes to stay ahead of or out in front of traffic.

A_Never. ~Sometimes I do .


24. I have tried to beat a red light. a. Never. b. Sometimes. C. Often.

(Dtery often.

25. ~dge and weave through traffic. ~ever.

b. Seldom. c. Often. d. Very often.

For the list of drugs below, circle the letter for the answer that best fits you. For alcohol, it is the number of times in your lifetime you have been intoxicated. For all other drugs, it is the number of times in your lifetime that you have used the drug . On the right side of the page opposite the drug, indicate the number of times in the last 12 months in the community, that you have been intoxicated on alcohol or you have used the other drugs. Circle "a" if you did not use alcohol or the other drugs in the past 12 months. Circle "b" if you were intoxicated on alcohol or used the other drugs from one to 10 times, etc .. Then for each drug that you have used in your lifetime, put your age you last used that drug.

Total Number of Times In Lifetime

One More Never to 10 11-25 26-50 than 50 used limes limes times limes

26. Number of times intoxicated or drunk on alcohol (beer, wine, hard liquor, a b C d mixed drinks).

Times used in the last 12 months

Age last used

27. Marijuana (pot, hashish, hash, THC, dope, etc). a

28. Cocaine (coke, snow, crack, rock, blow, etc.). 0 29. Amphetamlnes/methamphetamine/stimulants (meth, ice, crystal, Q)

speed, uppers, stimulants, diet pills, black beauties, bennies, white crosses, Dexedrine, Desoxyn, end other stimulants used for nonmedical reasons such as Ritalin, Adderall, etc.).

b

b

b

C

C

C

d

d

d

0

0 e

e

abc@,e 7D @cde

(!Pede

30. Hatlucinogens (LSD, acid, peyote, mushrooms, PCP, angel dust, a 0 C d e (Jbcde LB ecstasy, ketamine, etc.).

31. Inhalants (rush, gasoline, paint, glue, nitrous oxide, poppers, snappers, Q) b etc.).

32. Heroin (horse, H, smack, junk, etc.). 0 b

33. other opiates or pain killers used for nonmedical reasons (codeine, ~ b opium, morphine, Percodan, Oilaudid, Demerol, Methadone, Oxycodone, Oxycontin, Vicodin, Darvon, etc.).

34. Barbltuates/sedativea used for nonmedical reasons (Seconal, Nembutal, 0 b Amytal, Phenobarbital, Dalmane, quaaludes, placidyl, sleeping medicines, blues, reds, yellows, ludes, etc.).

35. Tranquilizers use for nonmedical reasons (Librium, Valium, Ativan , 0 b xanax, Serax, Miltown, Equanil, Halcion, meprobamates, etc.).

36. As to your use of cigarettes (tobacco).

Never smoked

a

Do not smoke now

b

Up to half pack a day

C

Upto a pack a day

0

C

C

C

C

C

d

d

d

d

d

e

e

e

e

e

30

@Pede

@cde

&cde

Qpcde

@cde

Up to two More than two packs a day packs a day

e

Have you u9ed alcohol or other drugs for any of the following reasons? Circle the letter for the answer that best fits you.

No Sometimes Often Very often

37, To have fun and relax? a b C G) 38. To relieve stress and tension? a b G) d

39. To feel less depressed? a 0 C d

40. To be less shy? a G) C d

41. To be able to express myself better? v b C d

42. To relieve your worries and troubles? a 0 C d

43. To forget your problems? a 0 C d

44. To calm youraelf down? a (9 C d 4

40

As a result of using alcohol or any of the other drugs on page 4, indicate how often any of the following have happened to you in your uretime. Then, for each of the following statements, in the column on the right side of the page, indicate how many limes it has happened to you in the last 12 months in the community. Circle an "a" if it did not happen to you, circle a "b" if it happened to you 1-3 times, circle a "c" if it happened to you 4-6 t,mes, circle a "d" if it happened to you 7-10 times and circle an ''e" if it happened more than 10 times.

Total Number of Times In Lifetime Number of More times in

1-3 4-6 7-10 than 10 the last Never limes times times times 12 months

45. Had a blackout (forgot what you did but were still awake). a G) C d e (3}b cde

46. Became physically violent. a b 0 d e (}bcde

47. Staggered and stumbled around. a b C CD e a€)cde

48. Passed out (became unconcious). a ® C d e (])bcde

49. Tried to take your own life. (!) b C d e G)bcde

50. Became physically sick or nauseated. a b C d 0 at@e

51. Saw or heard things not there. (0 b C d e ()bcde

52. Became mentally confused. 0 b C d e (jibcde

53. Thought people we re out to get you or wanted to cause you harm. 0 b C d e {3)b c de

54. Had physical shakes or tremors. 0 b C d e Qbcde

55. Had a seizure or a convulsion . 0 b C d e (!lb cd e

56. Had rapid or fast heart beat. 0 b C d e (3bcde

57. Became very anxious, nervous and tense. a b C d 0 ab@)de

58. Became feverish, hot or sweaty. a b C d 0 ab~

59. Did not eat or sleep. a b C d 0 a~e

60. VI/ere weak, tired and fatigued. a b C d 0_ abc<€)

61. Unable to go to work or school. a Q) C d e C}bcde

62. Neglected your family. a b C d 0 at@e

63. Broke the law or committed a crime. a b 0 d e a@cde

64. Could not pay your bills. CD b C d 8 (Jb cd e

AD eD cD sD sD

For the following questions, please choose the answer that best fits you. Hardly Yes Yes Yes, all at all sometimes A lot the time

65. Have you felt down and depressed? a

~ C d

66. Have you been nervous and tense? a C d

67. Have you been irritated and angry? a (9 C d

68. Have your moods been up and down - from very happy to very depre59ed? (v b C d

69. Do you tend to worry about things? a b C (!) 70. Have you felt like not wanting to !ive or taking your own llre? 0 b C d

71. Have you had problems sleeping? a b 0 d

72. Have you hed thoughts that upsat or disturb you? a

~ C d

73. Have you been discouraged about your future? a C d

5 rD

Please circle the letter for the answer for each question that best fits you.

74. Have you ever gotten angry at someone?

75. Have you lied about something or not told the truth?

76. Do you ever find yourself unhappy?

77. Have you felt frustrated about a job?

78. Do you hold things in and not tell others what you think or feel?

79. Have you bean unkind or rude to someone?

80. Have you ever cried about someone or something?

Please clrcle the letter for the answer for each question that best fits you.

81 . When I was in my teen years, I got into trouble with the law.

82. I was suspended or expelled from school when I was a child or teenager.

83. I have been In fights or brawls.

84 . I have been charged with driving while impaired or under the influence of alcohol or other drugs.

65. I have had trouble because I don't follow the rules.

86. I don't like police officers.

87. There are too many laws in society.

88. II Is all right to break tne law if it doesn't hurt anyone.

Please answer these questions as to how they apply to you during your lifetime and during the last 12 months in the community. Clrcle the letter for the answer of your choice.

89. Number of times I have received a ticket for a driving violation (speeding, driving without a license, running a red light, etc.).

90. When in the community, I have spent time with people who have been in trouble with the law.

91. My friends and/or family get inlD trouble with the law.

92. Whan I have broken the law, I have been high or under the influence of alcohol or other drugs.

93 When I have committed a crime, I knew that I was involved in Cfiminel behavior.

6

No Hardly Af ew Yes never at all times a lot

a G) C d

a b 0 d

a 0 C d

a b 0 d

a b 0 d

0 b C d

a 8 C d

10□

1-2 3-4 5 or more Never times times times

a 0 C d

© b C d

a 0 C d

a ~ C d

Not Somewhat Usually Always true true true true

(!) b C d

a 0 C d

a 0 C d

Q b C d

During Your Lifetime

5 or During 1-2 3-4 more the last

None times times times 12 months

a 0 C d ae)c d


During No A Most of the last

never So~es lot the time 12 months

a C d a@c d

a G) C d (j b c d

0 b C d b c d

oD a 0 C d @b c d

Please answer these questions as to how they apply to you during your lifetime and during the last 12 months In the community. Circle the letter for the answer of your choice.

94. As an adult, I have been in trouble with the law other than while driving a motor vehicle.

95. Number of times that I have been arrested and charge with a crime.

96. Number of times that I have been convicted of a crime (misdemeanor or felony).

97. Number of times my probation or parole has been revoked (circle "a" if never been on parole or probation).

98. Number of times I have been arrested for a crime committed against a person (such as robbery, burglary, assault, rape, manslaughter, murder).

99. Number of times I have been arrested for a domestic violence related offense.

Please answer these questions aa to how they apply to you during your lifetime and during the last 12 months. Circle the letter for the answer of your choice.

Never

100. Total amount oftime I have spent on probation.

101 . Total amount of time I have spent on parole.

102. Total amount of time I have spent in jail or prison.

103. 1 have been violent in my behavior or actions.


5 or During 1-2 3-4 more the last

None times times time11 12 months

0 b C d b Cd

a C0 C d

a 0 C d

0 b C d

0 b C d b c d

0 b C d


4 or During 1-6 7-12 1-3 more the last

months months years years 12 months

b C d e b c

b C d e b C

b C d e

During Your Lifetime During

No Very the last Never Sometimes Often often 12 months

a G C d b Cd

Total Number of Times in Lifetime

Please answer thase questions as to how they apply to you during your lifetime and during the last 12 months in the community. Circle the letter for the answer af your choice.

104 Number of times I have been sentenced for a crime to county jail.

105. Number of times I have been sentenced for a crime for which I have been on probation or conditional discharge or condition el supervision.

106. Number of times I have been sentenced for a crime to state or federal prison.

Please answer the following questions as to how you see yourself at this time.

1 07. Have you felt a need lo make changes in your use of alcohol or other drugs?

108. Do you want to stop using alcohol; or to continue not using alcohol?

1 09. Do you want to stop using other drugs; or continue not using other drugs?

110. Have you felt a need to have help with problems having to do with alcohol use?

111 . Have you felt a need to have help with problems with the use of other drugs?

112. Is It importsnt for you to make changes around the use of alcohol or other drugs?

Ne110r

0 a

Q)

113. VVould you be willing to come to (or continue in) a program where peop!e get help for alcohol or other drug use problems?

7

One Two time times

b C

b 8 b C

No not Yes at all maybe

a b

a b

a CD a 0 a b

a b

a 0

Number 4 or of times

Three more in last times limes 12 months

d e b c de

d e b c d a

d e b c d e

aD ED FD Yes most Yes

likely for sure

C €) 0 d

C d

C d

C 0 G) d

C d

110

ADULT SUBSTANCE USE AND DRIVING SURVEY - REVISED FOR ILLINOIS (ASUDS-RI) Authors: Kenneth W. Wanberg and David S. Timken

CLIENT INFORMATION

N<!me: Teddy Trouble Assess Date: 04/09/2019 Arrest BAC: .149 DOB: 12/06/1986 Client ID: 0001 Failed Blood/Urine Test: No Age: 20 Ev<!luator: rjk Prior DWI/DUI Convictions: O Gender: Male Agency Name: Don't Drive DUI Prior DWI/DUI Educiltion Hrs: 0 Ethnicity: Anglo-American White No. AOD OP Treatment Sessions: 8 Milrital Stiltus: Never married No. AOD Inpatient Days: O

DRUG AND ALCOHOL USE HISTORY

Drug Category Times in Times last 12 II Age Last Drug Times in Times last 12 lifetime months Use Category lifetime months

Alcohol Drunk More than 50 times 111-25 times IEJIHeroln II Never Used II Never Used

More than 50 126-50 t imes ID l Never Used Marijuana

times Other Opiate Never Used

I Coca ine II Never Used II Never Used N/A II Sedatives II Never Used II Never Used

I Amphetamines II Never Used II Never Used N/A I Tranquilizers I Never Used II Never Used

Hallucinogens One to 10 times I Never Used D Cigarettes II Up to a pack a

day I I Inhalants II Never Used II Never Used II N/A II II II

CRITICAL ITEMS

• Drove a few times when had too much to drink • Passed out often when drinking • Not recall what did when drinking twice • Blackouts 1-3 times • Physically violent 4-6 times • Passed out 1-3 times • Committed a crime 4-6 times • Charged w ith impaired driving 1-2 times • Arrested and charged with crime 1-2 times • Convicted of a crime 1-2 times • Violent behavior sometimes • Have problems sleeping a lot of the time • For sure, want to make changes in use of alcohol or other drugs • Most likely want to stop using or continue not to use alcohol

SUGGESTED SERVICE LEVEL BENEFITS OR GUIDELINES

j Level II Suggested Service Level Benefit

171 Client could benefit from a basic alcohol-drug / DUI risk education program plus an extended-enhanced ~I alcohol/drug treatment program fol lowed with an a~ercare plan.

Age Last Use

II~ IEJ II N/A I 11 N/A ! ID II I

II Weighted I 10

ASSESSMENT SUMMARY • Fairly open around driving risk behavior; may benefit from driving risk education • High level of past alcohol Involvement with very strong indication of a past disruptive pattern of alcohol problems. • Low-moderate defensiveness quite open to self-disclosure. • Moderate to high levels of mood and psychological distress. Consider mental health assessment if collateral information supports this. • Moderate to high past AOD involvement based on drugs {drugs include alcohol) listed in the survey. • Reports very significant AOD involvement in last 12 months. • Past AOD negative outcomes or consequences to indicate past moderate disruptive effects and problems with possible Substance Abuse Disorder. • Indicates low to moderate history of social-legal non-conforming. • Indicates moderate to high motivation and desire for change and reluctant to get help for AOD problems. • Overall history of psychosocial and AOD problems and disruption is very high.

ASSESSMENT SCALES Dedie ll.lnk

Percentile Low Low Medium I HigoMedillm High

1 2 ] 4 5 6 7 B !I 10 20 30 40 5C 6C 70 so ec

1. Alcohol Involvement: 25 98

2. Driving Risk: 9 89

3. AOD Involvement 1: 9 96

4. AOD Use Benefits: 17 98

5. AOD Disruption!: 34 98

6. AOD Last 12 Months: 22 99

7. Mood Adjustment: 10 97

8. Social Legal Non-Conformity: 14 79

9. Global AOD Psychological: 67 97

10. Defensive: 15 32

11. Motivation: 13 88

12. Involvement2: 9 30

13. Disruption2: 34 39 10 20 3IJ- 40 5C ec 1(1- BO llQ

Low low Meo:fum rligh Ma!dlum High P11n:11mHe

Dedie Rank Low low Medi,..,, I l-lighMl!dillm High

l 2 ] 4 5 6 7 l!I g 10 20 30 40 SQ eo 70 8(1 EIO

A. Behavioral Disruption: 11 52

B. Psychophysica I Disruption: 16 41

C. Social Role Disruption: 7 38

D. Social Non-Conforming: 8 80 E. Legal Non-Conforming: 6 80 F. Social-Legal Non-Conform 12 Mon.: 4 70

10 20 :JO 40 so M 70 M lil'.l

Low Low Medi,..,, I l-ligh Medium High Pen:emile

•AOD = alcohol or other drugs

10

10

Inform st ion in the ASUDS-RI summary is based on the client's self-report. It is dependent on his or her ability to validly respond to the questions. It represents the individual's perception af self l<lgarding alcohol and other drug use, driving attitudes and behaviors, oonoerns about self, relationship with the community, legal history, and willingness to be involved in the change process. This information should be used only in conjunction with information from all other sources when making referral, education or treatment recommendations. No one piece of information from this or any other source should be used solely to make such decisions When possible, It is helpful to engage ttie client in a partnership when making referral and treatment recommendations and decisions The final referral and treatment recommendations are always made by the evaluator

Client Signature: ___________________ ~Date· ______ _

Answer Sheet Questions arn based on user entry; 1 = A, 2 = B, 3 = C, 4 = D, 5 = E, 6 = F

1. 3 I 2. 3 I 3. 2 I 4. 4 I 5. 4 I 6. 2 I 7. 4 I a. 2 I 9. 3 I 10 3 I 11 3 I 12. 3 I 13 2 I 14. 2 I 15. 2 I 16. 1 I 17. 2 I 18 1 I 10. 1 I 20. 2 I 21. 1 I 22. 2 I 23. 2 I 24. 4 I 25. 1 I 26. s I 26a 3 I 26b. 20 I 27. s I 27a. 4 I 27b. 20 I 28. 1 I 28a. 1 I 28b.N/A I 29.1 I 29a 1 I 29b.N/A I 30.2 I 30a.1 I 30b 18 I 31.1 I 31a1 I 31b NIA I 32.1 I 32a.1 I 32b. NIA I 33. 1 I 33a. 1 I 33b NIA I 34. 1 I 34a. 1 I 34b. NIA I 35 1 I 35a. 1 I 35b. NIA I 36. 4 I 37. 4 I 38. 3 I 39. 2 I 40. 2 I 41. 1 I 42. 2 I 43. 2 I 44. 2 I 45. 2 I 45a. 1 I 46. 3 I 46a. 1 I 47 4 I 47a. 2 I 48 2 I 48a. 1 I 49. 1 I 49a. 1 I 50. 6 I 50a. 3 I 51. 1 I 51 a. 1 I 52. 1 I 52a, 1 I 53 1 I 53a. 1 I 54 1 I 54a 1 I 55. 1 I 55a. 1 I 56. 1 I 56a. 1 I 57. 5 I 57a. 3 I 58.5 I 58a.4 I 59.5 I 59a.3 I 60.6 I aoa s I 61.2 I a1a.1 I 62 5 I 62a.3 I 63.3 I esa.2 I 64.1 I 64a.1 I 65. 2 I 66. 2 I 67. 2 I as. 1 I 69. 4 I 70. 1 I 71. 3 I n. 2 I 73 2 I 74 2 I 75. 3 I 76. 2 I 77 3 I 78. 3 I 79. 1 I 80. 2 I s1. 2 I 82. 1 I 83. 2 I 84. 2 I 85. 1 I 86. 2 I 87. 2 I 88. 1 I e0, 2 I 89a. 2 I 90. 2 I 00a. 2 I 01. 2 I 91 a. 1 I 02. 1 I 02a 1 I 93. 2 I 93a. 1 I 94. 1 I 94a. 1 I 95. 2 I 95a. 2 I 96. 2 I 96a. 2 I 97. 1 I 97a. 1 I 98. 1 I 96a. 1 I 99. 1 I 99a. 1 I 1 oo. 1 I 100a.1 I 101. 1 I 101a 1 I 102 1 I 102a.1 I 103. 2 I 103a 1 I 104.1 I 104a 1 I 10s. 3 I 105a.1 I 1oe.1 I 1oea. 1 I 107.4 I 108.3 I 100.2 I 110.2 I 111.4 I 112.3 I 113.2 I

Documents

of Numan S.rvtc:• • DUI Service Reporting System (eDSRS ... · 2 $16,910 3 $21 330 4 $25 750 5 $30,170 6 $34.590 7 $39.010 8 $43.430 For each additional oerson add $4.420 The