Fla. Admin. Code R. 15A-10.043

Current through Reg. 50, No. 217; November 5, 2024

Section 15A-10.043 - Forms

The forms identified by this rule are listed below by number, title, and effective date. Each form is incorporated by reference. Copies may be obtained by contacting the DUI Programs Section, Neil Kirkman Building, Tallahassee, Florida 32399-0571.

(1) The following forms are not provided in volume by the Department rather the DUI program shall use forms in the same format and content:

(a) Ancillary Fee Request Form HSMV Form 77002 (effective 01-01-94, rev. 01-07-97);

(b) Client Tracking Form HSMV Form 77003 (effective 01-01-94, rev. 01-07-97);

(c) Client Data Information and Interview HSMV Form 77004 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(d) Treatment Referral and/or Documentation HSMV Form 77005 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(e) Notice of Change Form HSMV Form 77006 (effective 01-01-94, rev. 01-07-97);

(f) Assessment Fee Report Form HSMV 77007 (effective 01-01-94, rev. 6/94, 01-07-97);

(g) Student Observation/Incident Report HSMV Form 77008 (effective 01-01-94, rev. 01-07-97);

(h) Client Transfer Record HSMV Form 77009 (effective 01-01-94, 01-07-97);

(i) Instructor Evaluation Report HSMV Form 77010 (effective 01-01-94, rev. 01-07-97);

(j) Request to Release or Obtain Information HSMV Form 77011 (effective 01-01-94, rev. 01-07-97);

(k) Information Sheet Special Supervision Services HSMV Form 77012 (effective 01-01-94, rev. 01-07-97);

(l) Screening Form HSMV Form 77013 (effective 01-01-94, rev. 01-07-97);

(m) Statement of Abstinence by Applicant HSMV Form 77014 (effective 01-01-94, rev. 01-07-97);

(n) Personal History Form HSMV Form 77015 (effective 01-01-94, rev. 01-07-97);

(o) Incident Log HSMV Form 77016 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(p) Florida Department of Law Enforcement Request HSMV Form 77017 (effective 01-01-94, rev. 01-07-97);

(q) Client Rights/Appeal Process HSMV Form 77018 (effective 01-01-94, rev. 01-07-97);

(r) Statement of Abstinence from References HSMV Form 77019 (effective 01-01-94, rev. 01-07-97);

(s) Psychosocial Evaluation HSMV Form 77020 (effective 01-01-94, rev. 01-07-97);

(t) Referral for Required Chemical Testing HSMV Form 77021 (effective 01-01-94, rev. 01-07-97);

(u) Letter of Incomplete Application HSMV Form 77022 (effective 01-01-94, rev. 01-07-97);

(v) Letter of Recommendation HSMV Form 77023 (effective 01-01-94, rev. 01-07-97);

(w) Application for Appeal HSMV Form 77024 (effective 01-01-94, rev. 01-07-97);

(x) Periodic Update HSMV Form 77025 (effective 01-01-94, rev. 01-07-97);

(y) SSS Treatment Referral Form HSMV Form 77026 (effective 01-01-94, rev. 01-07-97);

(z) Letter Recommending Cancellation HSMV Form 77027 (effective 01-01-94, rev. 01-07-97);

(aa) Appointment Receipt HSMV Form 77028 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(bb) Client Annual Review Form HSMV Form 77029 (effective 01-01-94, rev. 01-07-97);

(cc) Staff Annual Review Form HSMV Form 77030 (effective 01-01-94, rev. 01-07-97);

(dd) Feedback HSMV Form 77031 (effective 01-07-97);

(ee) Monthly Update HSMV Form 77032 (effective 01-01-94, rev. 01-07-97); and,

(ff) Guidelines for Advanced Training HSMV Form 77033 (effective 09-95, rev. 01-07-97).

(2) The following forms are provided by the Department and must be original forms:

(a) DUI Program License HSMV Form 77034 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(b) Application for Licensure as a Driving Under the Influence (DUI) Program HSMV Form 77035 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(c) Driving Under the Influence License Renewal Form HSMV Form 77036 (effective 01-01-94, rev. 06-95, 01-07-97);

(d) Facility Inspection Form HSMV Form 77037 (effective 01-01-94, rev. 01-07-97);

(e) Compliance Review HSMV Form 77038 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(f) Site Visit Report HSMV Form 77039 (effective 01-01-94, rev. 01-07-97);

(g) Student Status Report HSMV Form 77057 (rev. 9/90, 1/97);

(h) Interstate DUI Transfer Form HSMV Form 77040 (effective 01-01-94, rev. 01-07-97);

(i) Preservice Instructor Training Documentation HSMV Form 77041 (effective 01-01-94, rev. 01-07-97);

(j) Application for DUI Personnel Certification HSMV Form 77042 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(k) Temporary Certificate HSMV Form 77043 (effective 01-01-94, rev. 01-07-97);

(l) Standard Certificate HSMV Form 77044 (effective 01-01-94, rev. 06-95);

(m) Application for Provider Status HSMV Form 77045 (effective 01-01-94, rev. 01-07-97);

(n) Individual Training Event HSMV Form 77046 (effective 01-01-94, rev. 01-07-97);

(o) Training Documentation HSMV Form 77047 (effective 01-01-94, rev. 01-07-97);

(p) Application for Conference Approval HSMV Form 77048 (effective 01-01-94, rev. 06-95);

(q) Criteria Checklist for Level II Curricula HSMV Form 77049 (effective 01-01-94, rev. 05-06-94, 01-07-97);

(r) Application for Treatment Waiver HSMV Form 77050 (effective 01-01-94, rev. 06-95);

(s) Quarterly Treatment Referral Report HSMV Form 77051 (effective 01-01-94, rev. 01-07-97);

(t) Request for Information from Driver License Records HSMV Form 73250 (rev. 6/89, 5/95);

(u) Final Order Denying Appeal HSMV Form 77052 (effective 01-01-94, rev. 01-07-97);

(v) Final Order Granting Appeal HSMV Form 77053 (effective 01-01-94, rev. 01-07-97);

(w) Driving Under the Influence Programs Complaint Form HSMV Form 77054 (effective 01-01-94, rev. 01-07-97);

(x) Client Complaint Resolution Form HSMV Form 77055 (effective 01-01-94, rev. 06-95, 01-07-97); and,

(y) Treatment Provider Information, HSMV Form 77056 (effective 01-07-97).

Fla. Admin. Code Ann. R. 15A-10.043

Rulemaking Authority 322.02, 322.292, 322.293 FS. Law Implemented 322.02, 322.292, 322.293 FS.

New 1-4-95, Amended 3-4-97.

New 1-4-95, Amended 3-4-97.