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Correctional Services Act, 1998 (Act No. 111 of 1998)

Regulations for the Administration of the Department of Correctional Services of the Republic of South Africa

Schedule B – 2012

Medical Parole Application in terms of section 79 of Act 111 of 1998 as amended

 

A. DETAILS OF OFFENDER

 

1. Registration No.

2. Surname and Initials

3. Date of Birth

4. Gender

5. Correctional Centre at which detained

 

 

1. I, ..................................................................... (Name and Surname) hereby consent to the full disclosure of my medical information to the extent necessary and to the persons necessary in order to process this application for medical parole. I also agree, that should I be granted medical parole, to undergo periodic medical examination by a medical practitioner in the event that this is required.

 

 

SIGNATURE OR RIGHT THUMB PRINT         SURNAME AND INITIALS AND SIGNATURE OF WITNESS

 

B DETAILS OF APPLICANT (If different from A)

 

1. ID No.

2 Surname and Initials

3. Date of Birth

4 Relationship to Offender

 

C. MEDICAL REPORT - to be completed by medical practitioner

 

1. Name and Surname of .___________________2. Practice number:____________________

Medical Practitioner

 

3. I examined the offender on_____________________at________________________

 

4. I    did    did not    Refer the offender for a specialist opinion.

(if referral to specialist attached separate report)

 

5.

a) Diagnosis_____________________________________________________________________________________________________________________________________________________________________________________________
b) Medical history_________________________________________________________________________________________________________________________________________________________________________________________________
c) Is the offender suffering from a terminal disease or condition as specified in the conditions listed in Regulation 29A (5)?_______________________________________________________________
d) What is the prognosis?_________________________________________________________
e) Is the offender able / unable to perform activities of daily living and self care due to the above mentioned?

Comments: ________________________________________________________

f) If unable, date of unset or period he /she suffered from the condition / diseases / incapacity?

_____________________________________________________________________________________________________________________________________________________________________________________________

g) Is the impact of the illness or condition on activities of daily living and self care, mental, physical and intellectually capacity minor, moderate or severe? Please explain:

________________________________________________________________________________________________________________________________________________________________________________________________

h) Has the offender's condition deteriorated permanently or reached and irreversible state? If yes, explain briefly:

_________________________________________________________________________________________________________________________________________________________________________________________________

i) How has the offender managed?

_____________________________________________________________________________________________________________________________________________________________________________________________

 

7. Response to treatment

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

8. Medical parole should be considered for the following reasons:

8.1. Functional or physical incapacity: ____________________________________________
8.2. Mental or intellectual capacity:_______________________________________________
8.3. Unable to provide self care:_________________________________________________

 

9 In your professional opinion does the condition of health render the offender incapable of committing further criminal acts, in particular of sexual and / or violent nature?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10 If released, the offender would require the following health care:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11 The health care required in 10 above is available in the area in which the offender will reside?

(Specify health capacity, hospice, home care etc)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name: __________________ __            Date:_____________________

(BLOCK CAPITALS)

Signature:--------------------

 

D. DETAILS OF OFFENCE, SENTENCES AND REHABLITATION- to be completed by CMC

 

1 Was the sentencing court aware of the current condition of the offender?

Attached SAP62, SAP 69 and sentencing remarks where available

 

2. Type of offence

______________________________________________________________________________________________________________________________________________________________________________________________________________________

 

3. Date of sentence____________________________________________________________

 

4. Length of sentence___________________________________________________________

 

5. Previous Convictions

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7 Name of Court.

Case number

 

8 What programmes has the offender attended?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9 What is your assessment of the risk of the offender re-offending given his present medical condition

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10 Attach latest social work report

 

11 Has the offender been found guilty of any disciplinary offences whilst in detention? (specify)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

E. ARRANGEMENTS FOR offender's SUPERVISION, CARE AND TREATMENT -to be completed by Community Corrections

 

a) Where will the offender be accommodated after release on medical parole

 

I. Hospice

I. Hospital

I. Friends or Family

I. Other (Specify)

 

 

Address

______________________________________________________________________________________________________________________________________________________________________________________________________

a) Is the address monitorable?_____________________________
b) Who will care for the offender and what is their relationship?

______________________________________________________________________________________________________________________________________________________________________________________________________

c) To what extent are the relatives and friends aware of the offender's medical condition?

______________________________________________________________________________________________________________________________________________________________________________________________________

d) Are relatives and friends able to take care of the offender in his/her present condition?

______________________________________________________________________________________________________________________________________________________________________________________________________

e) If the offender is to be accommodated in a hospital, hospice or other institution what arrangement has been made with such institution?

______________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Name: ______________ _          Date:________________

(BLOCK CAPITALS)

Signature: ______________ _

 

Commencement

These regulations shall come into operation on_______________________2011