Form Preview Example

PROTECTIVE ORDERS

Data Entry Form for

TEXAS CRIME INFORMATION CENTER (TCIC)

The intent of this form is to aid court clerks with the collecting and providing to local law enforcement agencies pertinent information regarding protective orders for the purpose of entry into TCIC.

To be filled out by Criminal Justice/Law Enforcement Official:

ORI:	(check one) Protective Order:	Emergency Protective Order:

OCA:	Protective Order No:	Court Identifier:

Issue Date:	Date of Expiration:	Date of Dismissal:

*** RESPONDENT INFORMATION ***

Items in ALL UPPERCASE LETTERS must be answered to allow entry into TCIC.

NAME OF RESPONDENT: _____________________________________________________Sex: (circle one) M F

Race: (circle one) Indian Asian Black White Unknown Ethnicity: (circle one) Hispanic Non-Hispanic Unknown

Place of Birth: ________ CTZ: _______ Date of Birth: _________ Height: _______ Weight: _________

Skin: (circle one) Albino Black Dark Dk Brown Fair Light Lt Brown Medium Med Brown Olive Ruddy Sallow Yellow Unknown

Eye Color: (circle one) Black Blue Brown Gray Green Hazel Maroon Pink Multi-Colored Unknown

Hair Color: (circle one) Black Blond Brown Gray Red White Sandy Bald Unknown

Scars, Marks and/or Tattoos: (please describe in detail):________________________________________________

________________________________________________________________________________________________

Caution and Medical Conditions: (circle all that apply) 00 – Armed and Dangerous 05—Violent Tendencies 10—Martial Arts Expert 15—Explosive Expertise 20—Known to abuse drugs 25—Escape risk 30—Sexually violent predator 50—Heart condition 55—Alcoholic 60—Allergies 65—Epilepsy 70—Suicidal 80—Medication Required 85—Hemophiliac 90—Diabetic 01--Other

PROTECTION ORDER CONDITIONS (PCO): (circle all that apply)

01—Respondent is restrained from assaulting, threatening, abusing, harassing, following, interfering with or stalking the protected person and/or child of the protected person.

02—Respondent may not threaten a member of the protected person’s family/household.

03—The protected person is granted exclusive possession of the residence/household.

04—Respondent is required to stay away from the residence, property, school or place of employment of the protected person or other family or household member.

05—Respondent is restrained from making any communication with the protected person including, but not limited to, personal, written, or phone contact, or their employers, employees or fellow workers, or other whom the communication would be likely to cause annoyance or alarm.

06—Respondent is awarded temporary custody of the child(ren) named.

07—Respondent is prohibited from possessing and/or purchasing a firearm or other weapon.

08—See miscellaneous field for comments regarding the terms and conditions of the protection order.

09—The protected person is awarded temporary exclusive custody of the child(ren) named.

BRADY RECORD INDICATOR (BRD): N—Respondent is NOT disqualified Y—Respondent is disqualified U--Unknown

RELATIONSHIP TO PROTECTED PERSON: ______________________________________________________

( PLEASE INCLUDE THE FOLLOWING NUMERIC IDENTIFIERS, IF AVAILABLE):

Texas I.D. No: _________________ Misc I.D. No: ___________________ Social Security No: _________________

Driver's License No: _____________________ Driver's License State: _________ Date of Expiration: __________

RESPONDENT’S ADDRESS:

STREET: ______________________ CITY: __________ STATE: _____ ZIP: ____ COUNTY: __________

TEXAS DEPARTMENT OF PUBLIC SAFETY (JANUARY 1996) REVISED: 11/2012

PROTECTIVE ORDER DATA ENTRY FORM-TCIC RESPONDENT’S NAME_____________________

Respondent’s Vehicle Information:

License Plate No: ____________ L.P. State: __________ L.P. Year Of Expiration: _____ L.P. Type: __________

Vehicle I.D. #: ________________ Year: ______ Make: ________ Model: _________ Style: _______ Color: _____

Is the Respondent, at time of issuance of an original or modified protection order, a member of the state military

forces or serving in the U.S. armed forces in active duty status: (circle one) Yes No

Section 85.042 requires the court of the court to provide a copy of the protective order to the staff judge advocate at Joint Force Headquarters or to the provost marshal of the military installation to which the respondent is assigned to notify the commanding officer, as applicable.

Installation Respondent assigned to: _______________________________________________________________

Installation’s address:____________________________________________________________________________

*** PROTECTED PERSON INFORMATION ***

NAME OF PROTECTED PERSON: _____________________________________________ SEX: (circle one) M F

RACE: (circle one) Indian Asian Black White Unknown Ethnicity: (circle one) Hispanic Non-Hispanic Unknown

DATE OF BIRTH: _________________ SOCIAL SECURITY NO. (PSN):_______________________________

Street: ________________________ City: _____________ State: _____ Zip: _______ COUNTY: _______________

Protected Person Employment Information: (use additional pages if necessary)

Place of Employment Name: ___________________________ Address: ___________________________________

_________________________ City: ______________________ State: _________________ Zip: ________________

Place of Employment Name: ___________________________ Address: ___________________________________

_________________________ City: ______________________ State: _________________ Zip: ________________

*** PROTECTED CHILD INFORMATION ***

(Use additional pages if necessary)

Name of Protected Child: _______________________________________________________ Sex: (circle one) M F

Race: (circle one) Indian Asian Black White Unknown Ethnicity: (circle one) Hispanic Non-Hispanic Unknown

Date of Birth: _______________ Child Care or School Facility Name: ____________________________________

Address: ______________________________________ City: ________________ State: _________ Zip: ________

Name of Protected Child: _______________________________________________________ Sex: (circle one) M F

Race: (circle one) Indian Asian Black White Unknown Ethnicity: (circle one) Hispanic Non-Hispanic Unknown

Date of Birth: _______________ Child Care or School Facility Name: ____________________________________

Address: ______________________________________ City: ________________ State: _________ Zip: ________

To be filled out by Criminal Justice/Law Enforcement Official:

SID #:

FBI #:

FPC:

MNU: