Rc-Rrp-503 - Authorization For The Transfer And/or Release Of Assessment Results

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AUTHORIZATION FOR THE TRANSFER AND/OR RELEASE OF ASSESSMENT RESULTS
SECTION 1:
Student/Offender Information (Student/Offender must complete this Section)
______________________________________________________________________________________
Last Name
Suffix (Jr., Sr., III)
______________________________________________________________________________________
First Name
Middle Name (if applicable)
______________________________________________________________________________________
Date of Birth
Social Security Number (if applicable)
SECTION 2
: Transfer Type (Student/Offender must complete this Section)
I request that my Assessment results be transferred and/or released for the following reason:
Release/Transfer of Assessment results to a Clinical Evaluator
Release/Transfer of Assessment results to another Risk Reduction Program
Release/Transfer of Assessment results to a Court Official, Probation Officer, Employer
SECTION 3:
Transfer Information (Student/Offender or Program initiating transfer must
complete this Section)
Name of Program Assessment results Released by/Transferred FROM:
__________________________________________________________________
______________
Program Name
Certification No.
__________________________________________________________________
______________
Student / Offender’s Certificate of Completion #
Date of Completion
Name of Program or Clinical Evaluator Assessment results Release or Transferring TO:
_________________________________________________________________
______________
Program/Clinical Evaluator Name
Certification No.
SECTION 4:
This Section should only be completed by the Student/Offender if Assessment
results are being released/transferred to someone other than a Risk Reduction Program or Clinical
Evaluator (Court, Probation Officer, Employer, etc.)
______________________________________________________________________________________
Name of Person or Organization Receiving Assessment Results
SECTION 5:
Department of Driver Services Approval
____________________
Reason for transfer of Assessment results to another Risk Reduction Program:
Course Cancellation
Ga. Admin. Comp. Ch. 375-5-6-.14(c)(1)
Student/Offender has moved +30 miles from where assessed
Ga. Admin. Comp. Ch. 375-5-6-.14(c)(2)
Program closure/Temporary Closure
Documented Emergency
Ga. Admin. Comp. Ch. 375-5-6-.14(c)(3)
I do hereby authorize and release the above-referenced program to transfer and/or release my Assessment results to the
Program, Clinical Evaluator, or other person/organization named herein. I understand that I may be charged a fee of up to
$25 to have my Assessment results transferred to a Clinical Evaluator or to have my Assessment results transferred to another
program, if I have moved more than 30 miles from where I was assessed. I further understand that this release authorization
shall remain valid for a period of 90 days and may be revoked at any time, if done so in writing.
Signature of Student/Offender
Name of DDS Official Approving Transfer
Signature of Program Official Initiating Transfer
Date
IMPORTANT
(1) Verbal approval from the Department of Driver Services is required before Assessment results can be transferred to
another Risk Reduction Program.
(2) The name of the DDS official approving the transfer must be documented on this form.
(3) Approval may be obtained by contacting 678-413-8745 by 4:00 p.m. Monday through Friday, excluding holidays.
RC-RRP-503 (05/10)

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