APS - Agency Information Form

Annual Probation Survey – Agency Information Form
Please respond to the questions below. Send the completed form via fax to (866) 509-7471 or via e-mail to bjs-apshelp@rti.org by DATE. If you have any questions, please call the RTI Agency Support Team at (866) 334-4175.
Agency Name: ___________________________________________________________________________________
Does the agency have responsibility for supervising adults on any form of probation? Include active
supervision as well as inactive supervision, sometimes called “bench probation.” We’re interested in any
form of probation that entails monitoring or surveillance with or without any reporting requirements.

Yes
No

If the agency does not have responsibility for supervising any adults on any form of
probation, is there a chance that it will have this responsibility at any time in the next year?

Yes
No

If the agency supervises adult probationers, on December 31, 2016, how many adult probationers did your
agency supervise? Please provide a breakdown between number of felons and misdemeanants on that date.
Felons: ________________

Misdemeanants: ________________

Total: ________________

Please provide contact information for your agency.
Data Provider The most knowledgeable
person to provide data on adult probation.

Head of Agency
Check here if same as Data Provider □

Salutation (e.g., Mr. or Ms.) _________________________________

_________________________________

First Name

_________________________________

_________________________________

Last Name

_________________________________

_________________________________

Title

_________________________________

_________________________________

Mailing Address

Street: ___________________________

Street: ___________________________

City, State: _______________________

City, State: _______________________

Zip: _____________________________

Zip: _____________________________

Phone Number

_________________________________

_________________________________

Fax Number

_________________________________

_________________________________

E-mail Address

_________________________________

_________________________________

This collection has been approved by the Office of Budget and Management (OMB No. 1121-0339: Approval Expires 02/28/2019).
The burden of this collection is estimated to average 10 minutes per response, including reviewing instructions, searching existing
data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this form, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh
Street, NW, Washington, DC 20531. Do not send your completed form to this address.