Addictions and Mental Health Division

Addictions Policy and Program Development

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ADES Monthly Report

Please enter complete information. Incomplete forms may be returned.

Name of ADES: / Month of / , 20
Agency: / County:
Address: / Phone:
Email:

NOTE: ADES must submit a report each month, even if no interviews were done. Failure to report regularly may jeopardize certification.

NOTE: Individuals who were simultaneously charged with DUII and Marijuana possession must be referred to an approved DUII program.

Date of interview / Name of individual / Date of birth / List one:
Oregon driver license number, reference number, customer service number or
ID number / SID number / DUII Diversion / DUII Conviction / Marijuana Diversion / MIP — 2nd offense / DUII BAC / Indicate info or tx “I” / “T”
No Referral “NR” / TCU/Risk Score / Check RDL / Name of treatment provider
(No numbers) / Out–of–state
State referred to
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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