Attachment A.pdf

This is a Contractual Services Referral Eligibility Form used by the South Carolina Department of Probation, Parole and Pardon Services (SCDPPPS) to track and document approved contractual treatment service participants. The form is designed to record weekly submissions of participants who received services during the prior week, with designated space for up to ten participant entries. Required information fields include participant name, State ID number, date of birth, supervising agent, county, program assessment date, and projected service end date. Each entry must be marked as either eligible or ineligible for continued services. The form requires a SCDPPPS signature and submission date to validate the referral documentation.

This form serves as an internal administrative tool for the SCDPPPS sex offender treatment program, enabling the department to maintain accurate records of active treatment participants and monitor service delivery compliance. The document does not specify pricing, funding amounts, or contract terms, as it functions as an operational tracking mechanism rather than a procurement document. Providers submitting this form are expected to complete it only for approved participants who actively received contractual treatment services within the specified timeframe, ensuring data accuracy and program accountability.