FLORIDA DEPARTMENT OF CORRECTIONS

SUPERVISION REPORT
(FOR THE MONTH OF ____________________)

NAME: ___________________________________________________________ DC#: ________________________________________

OFFICER NAME/LOCATION: ______________________________________________________________________________________________

RESIDENCE:

Street Address: ________________________________________________ City: _____________________________ Zip: _____________

Building: ______________ Apt#: ______________ Lot#: _____________ Code to access security gate: _____________________

LIST FULL NAMES, AGES, AND RELATIONSHIP OF OTHERS WHO CURRENTLY LIVE AT THIS RESIDENCE (Note if anyone is on supervision):

________________________________________________________ ________________________________________________________

________________________________________________________ ________________________________________________________

HOME PHONE NUMBER: CELLULAR PHONE NUMBER:

EMAIL ADDRESS:

MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE):

VEHICLE - ____________________________________________________________________________________________________________
MAKE MODEL YEAR COLOR TAG#

CHECK CURRENT STATUS OF DRIVER’S LICENSE: Valid Revoked (Date:__________________) Suspended (Date:_____________)
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EMPLOYMENT:

Employer Name: ___________________________________________ _____________

Supervisor Name: Phone: ____

Employment Address: ____________________________________________________________________________________________

Your job title: _________________________________________________________________________________________________________

Job Duties: ___________________________________________________________________________________________________________

SALARY/INCOME EARNED (for past month): ____________________ DATE BEGAN: DATE ENDED: ________________

Typical Days/Hours Worked: _____________________________________________________________________________________________

NOTE: If unemployed (and not retired, disabled or a full-time student), attach completed Job Search form or list for the month.
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STUDENT/SCHOOL: N/A

Type of Class/School Attending: High School College Adult Education Vocational Other Course Online Classes

School/Class Name: ___________________________________________________ Phone#:

Address: ____________________________________________________________________________________________
Street City State Zip
Total Semester/Quarter Hours Enrolled:

Date Class or Semester Began: Date Ended: (Attach proof of enrollment or ending report)
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Page 1 of 2 - Please complete the other/reverse side of this report (OVER)
DC3-2026 (Effective 2/14) Incorporated by Reference in Rule 33-302.110, F.A.C. 2 Part File-Right Side
6 Part File-Section 2
SPECIAL CONDITIONS OF SUPERVISION – List progress made this past month on special conditions ordered, including:
PUBLIC SERVICE HOURS: ______________________ MONETARY PAYMENT: ______________________ OTHER: ______________________
TREATMENT ATTENDED THIS PAST MONTH: ________________________________________________________________________________
NOTE: Attach required Support Group Attendance forms, driving logs, public service work documentation, etc. as required.

PAYMENTS: Payments may be made by either U. S. Mail or credit card using one of the services described on the DC Public Web site,
www.dc.state.fl.us under the Probation link “FAQS” - Frequently Asked Questions– Four Ways to Pay Court Ordered Payments.

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CONTACT WITH LAW ENFORCEMENT – If you had any contact with law enforcement this past month, explain details here: _________________

_____________________________________________________________________________________________________________________

Do you have a problem or concern you would like to discuss with your probation officer? YES NO

How did you spend your free time last month? _________________________________________________________________________________
________________________________________________________________________________________________________________________

PERSONAL GOALS: Write each of your top 2 goals you are working to achieve. Indicate at least 2 action steps you took last month and 2 action
steps you will take this month to achieve each goal.
GOAL # 1:
________________________________________________________________________________________________________________________

__________________________________________________
ACTION STEPS I TOOK LAST MONTH:
1. __________________________________________________________________________________

2. __________________________________________________________________________________

ACTION STEPS I WILL TAKE THIS MONTH:

2. __________________________________________________________________________________

GOAL # 2:
________________________________________________________________________________________________________________________

__________________________________________________

ACTION STEPS I TOOK LAST MONTH:

2. __________________________________________________________________________________

ACTION STEPS I WILL TAKE THIS MONTH:

2. __________________________________________________________________________________

________ _____________
Signature Date

Signature of Officer Receiving Report Date Report Reviewed

Officer Comments:

DC3-2026 (Effective 2/14) Incorporated by Reference in Rule 33-302.110, F.A.C.