Form KDOC-0130 "Conditional Release Placement Exception Request" - Kansas

What Is Form KDOC-0130?

This is a legal form that was released by the Kansas Department of Corrections - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the Kansas Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form KDOC-0130 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

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Download Form KDOC-0130 "Conditional Release Placement Exception Request" - Kansas

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CONDITIONAL RELEASE PLACEMENT EXCEPTION REQUEST
Community Supervision Standard 04-131 requires an exception be approved by the residing JCF Program Director for
any youth releasing from a Juvenile Correctional Facility on Conditional Release to be placed in a residential placement.
This form should be completed and sent via email to the residing JCF Program Director 45 days prior to the youth’s
release (when applicable). The Program Director will reply within five (5) business days of receipt of this request.
Youth Name:
Age:
Judicial District:
Permanency Goal:
Projected JCF Release Date:
YLS Risk Level:
Exception Justification: (check all that apply) (documentation for each exception must be included upon submission for
any exception)
_____ The youth’s victims reside in the parent/family/guardian(s) home and there is a documented therapeutic reason
(from the Court, therapist, victim services, DCF) to not allow contact, or a no-contact order is in place.
_____ The youth’s parent/family/guardian placement options have been explored and are exhausted. (May be due to
age, disability, refusal, etc.)
_____ The youth’s parent/family/guardian(s) are unavailable (death, deportation, incarceration, whereabouts unknown,
rights terminated).
_____ The youth’s parent/family/guardian have an active (pending disposition) DCF investigation.
_____ The youth’s parent/family/guardian(s) has criminal activity concerns that are documented by law enforcement
within the last thirty (30) days.
_____ The youth has an established educational opportunity that requires residential placement.
_____ Other (please specify in the narrative section below)
*Indicates the request will not be available within the 45 days submission criteria and should be submitted as soon as
screen are complete.
_____ *Youth has an approved PRTF admission screen.
_____ *Youth has an approved in-patient drug/alcohol screen.
Additional narrative justifying placement exception request:
State of Kansas
Kansas Department of Corrections
Form: KDOC-0130
Revised: October 2015
CONDITIONAL RELEASE PLACEMENT EXCEPTION REQUEST
Community Supervision Standard 04-131 requires an exception be approved by the residing JCF Program Director for
any youth releasing from a Juvenile Correctional Facility on Conditional Release to be placed in a residential placement.
This form should be completed and sent via email to the residing JCF Program Director 45 days prior to the youth’s
release (when applicable). The Program Director will reply within five (5) business days of receipt of this request.
Youth Name:
Age:
Judicial District:
Permanency Goal:
Projected JCF Release Date:
YLS Risk Level:
Exception Justification: (check all that apply) (documentation for each exception must be included upon submission for
any exception)
_____ The youth’s victims reside in the parent/family/guardian(s) home and there is a documented therapeutic reason
(from the Court, therapist, victim services, DCF) to not allow contact, or a no-contact order is in place.
_____ The youth’s parent/family/guardian placement options have been explored and are exhausted. (May be due to
age, disability, refusal, etc.)
_____ The youth’s parent/family/guardian(s) are unavailable (death, deportation, incarceration, whereabouts unknown,
rights terminated).
_____ The youth’s parent/family/guardian have an active (pending disposition) DCF investigation.
_____ The youth’s parent/family/guardian(s) has criminal activity concerns that are documented by law enforcement
within the last thirty (30) days.
_____ The youth has an established educational opportunity that requires residential placement.
_____ Other (please specify in the narrative section below)
*Indicates the request will not be available within the 45 days submission criteria and should be submitted as soon as
screen are complete.
_____ *Youth has an approved PRTF admission screen.
_____ *Youth has an approved in-patient drug/alcohol screen.
Additional narrative justifying placement exception request:
State of Kansas
Kansas Department of Corrections
Form: KDOC-0130
Revised: October 2015
By signing below, I acknowledge that it is in the best interest of the youth referenced above to be placed in a
residential placement following his/her discharge from the juvenile Correctional Facility.
______________________________
______________________________
__________________
Supervision Officer Name
Supervision Officer Signature
Date
______________________________
______________________________
__________________
Supervision Supervisor Name
Supervision Supervisor Signature
Date
______________________________
______________________________
__________________
JCF Program Director (or designee) Name
JCF Program Director (or designee) Signature
Date
_____: Approved
_____: Denied
Additional narrative justifying why an exception was denied.
The below is for the appeal process only.
Additional narrative justifying why an appeal is being requested.
______________________________
______________________________
__________________
Central Office (or designee) Name
Central Office (or designee) Signature
Date
_____: Approved
_____: Denied
State of Kansas
Kansas Department of Corrections
Form: KDOC-0130
Revised: October 2015
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