Florida Administrative Code › 15 - DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES › 15A - Division of Driver Licenses › Chapter 15A-10 - DUI PROGRAMS › Section 15A-10.043 - Forms

Current through Reg. 50, No. 138; July 16, 2024
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).