ADDICTIONS AND MENTAL HEALTH DIVISION
Addictions Policy and Program Development
ADES Monthly Report
Please enter complete information. Incomplete forms may be returned.
Name of ADES:
Agency:
Address:
Month of
County:
Phone:
Email:
, 20
NOTE: ADES must submit a report each month, even if no interviews were done. Failure to report regularly may jeopardize certification.
Name of treatment
provider
(No numbers)
Out–of–state
State referred to
Check RDL
TCU/Risk Score
Indicate info or tx “I” / “T”
No Referral “NR”
DUII BAC
SID number
MIP — 2nd offense
Date of
birth
Marijuana Diversion
Name of individual
DUII Conviction
Date of
interview
List one:
Oregon
driver
license
number,
reference
number,
customer
service
number or
ID number
DUII Diversion
NOTE: Individuals who were simultaneously charged with DUII and Marijuana possession must be referred to an approved DUII program.
1.
2.
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7.
8.
9.
10.
11.
12.
Send completed reports, by the 10th of the following month, to:
OHA 8050 (11/11)
DUII Information Specialist, Addictions and Mental Health Division, 500 Summer Street NE, E86, Salem, OR 97301-1118 or FAX: 503-378-8467