INSTRUCTIONS: Please fill in your event number and name and substance using information. Check the boxes if there has been any change since the last report, then fill in appropriate information. If this is your first time filling in the form, fill in all fields completely.

Event Number:
Last Name:
Middle Name:
First Name:
	Have you used alcohol, drugs, or other mind/mood altering substances which you were not prescribed since your last report? Yes No If yes when:
What were the substances?
Describe what happened:

Check the boxes if there has been any change since the last report
	Street Address: City Zip Code If this is an Oxford / Supported living house, which house is it? Who else resides at residence- Name and relation
	Curfew Phone Number (Should be a house land line): Invalid format.
	Cell Phone Number: Invalid format.
	E-mail: Invalid format.
	School / Employer Name:
	Employer Phone:
	Part- Time or Full-Time and Position:
	Law Enforcement Contact Since last Report? Yes No
	If yes, Date:
	Description:
	Medical/Dental Contact since last report? Yes No
	If yes, Date:
	Description, including time in and out and the location/physician/doctor name:
	Were you prescribed any medication? Yes No
	If yes, name of medication and quantity:
	Did you have a Medical Verification form filled out? Yes No
	One good thing that happened with your sobriety this week:

Clark County Superior Court Administrator: Jeffrey Amram
Street Address: 1200 Franklin Street, Vancouver, WA 98660
Main phone: (360) 397-2150
Speech-to-Speech Relay Service (800) 833-6384
Telebraille (800) 833-6385
TTY and Baudot (800) 6388 Responsible Elected Official: Judge Robert L Harris

For questions or comments regarding the Clark County Web site: Webmaster@clark.wa.gov