17.1 Juvenile Custody Report - Oregon Page 3

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17.1.3 – JUVENILE CUSTODY LOG
CASE#: ________-___________ _ DPSST#: _______________ AGE: __________ DOB: _____/_____/______
PARENTAL/GUARDIAN CONSENT: ___ Yes ___ No
1
RACE/ETHNICITY ABV. _________
SEX/GENDER ABV. _________ ORIGINAL OFFENSE: _____________________ MOST SERIOUS: ____________________
2
3
DATE/TIME/CUSTODY STATUS (IN):
_____/______/______-___________hrs. STATUS: __
__
4
Secure
Nonsecure
DATE/TIME/CUSTODY STATUS (OUT): _____/______/______-_________ __hrs. STATUS: __
__
RELEASED TO: ________________________
5
Secure
Nonsecure
CASE#: ________-___________ _ DPSST#: _______________ AGE: __________ DOB: _____/_____/______ PARENTAL/GUARDIAN CONSENT: ___ Yes ___ No
RACE/ETHNICITY ABV. _________ SEX/GENDER ABV. _________ ORIGINAL OFFENSE: _____________________ MOST SERIOUS: _____________________
DATE/TIME/CUSTODY STATUS (IN):
_____/______/______-___________hrs. STATUS: __
__
Secure
Nonsecure
DATE/TIME/CUSTODY STATUS (OUT): _____/______/______-_________ __hrs. STATUS: __
__
RELEASED TO: ________________________
Secure
Nonsecure
CASE#: ________-___________ _ DPSST#: _______________ AGE: __________ DOB: _____/_____/______ PARENTAL/GUARDIAN CONSENT: ___ Yes ___ No
RACE/ETHNICITY ABV. _________ SEX/GENDER ABV. _________ ORIGINAL OFFENSE: _____________________ MOST SERIOUS: _____________________
DATE/TIME/CUSTODY STATUS (IN):
_____/______/______-___________hrs. STATUS: __
__
Secure
Nonsecure
DATE/TIME/CUSTODY STATUS (OUT): _____/______/______-_________ __hrs. STATUS: __
__
RELEASED TO: ________________________
Secure
Nonsecure
CASE#: ________-___________ _ DPSST#: _______________ AGE: __________ DOB: _____/_____/______ PARENTAL/GUARDIAN CONSENT: ___ Yes ___ No
RACE/ETHNICITY ABV. _________ SEX/GENDER ABV. _________ ORIGINAL OFFENSE: _____________________ MOST SERIOUS: _____________________
DATE/TIME/CUSTODY STATUS (IN):
_____/______/______-___________hrs. STATUS: __
__
Secure
Nonsecure
DATE/TIME/CUSTODY STATUS (OUT): _____/______/______-_________ __hrs. STATUS: __
__
RELEASED TO: ________________________
Secure
Nonsecure
Applies to status offenders and youth in protective custody only.
1
White (W) | Black (B) | Hispanic (H) | Pacific Islander (PI) | Other (O)
2
Male (M) | Female (F) | Transgender Male (TM) | Transgender Female (TF)
3
Date/Time custody began within the facility, including whether the youth was confined in secure/nonsecure custody upon entry.
4
Date/Time custody ended within the facility, including whether the youth was confined in secure/nonsecure custody upon exit.
5

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