RESTORATION
JOB, INC.

…Helping Ex-Offenders Make a
“Positive Transition to a New Life”

EX-OFFENDER QUESTIONNAIRE

The purpose of this Questionnaire is to
hear directly from the ex-offenders who have had a long-term jail or prison
experience, so that we can find out what is needed in a transitional facility
to help the ex-offender increase their self-esteem and look forward to a
positive experience in re-entering society, so that their hopes for the future
will be positive.  It is our purpose
to provide such a facility and help decrease  the percentage of repeat offenders.

Name:
_______________________________       Age:
_______          DOB:
__________         Date:
______________________

Address:
_____________________________       Telephone:  _____________________________________

_____________________________      Cellular:
_____________________________________

Date of Arrest:          ________________________              What
Facility? __________________________________________

What County:                         ___________________          Family
or Support?_______________________________________

Charge(s)
_____________________________      Sentence/Term
of Incarceration
____________________________________

Term of Incarceration:
___________________     Were You Guilty:  __________ Yes  _______ No

Age at Time of Incarceration:  _____________     Age At Time of Release:_______

How Many Times Incarcerated?
____________

1.             How
do you feel you handled your incarceration?
_______________________________________________________

_______________________________________________________________________________________________

2.             How
much notice did you get before being released from prison or jail?

_______________________________________________________________________________________________

3.             Were
you released to a half-way house or other transitional facility?
________________________________________

If
so, name of facility?  ____________________________________________________________________________

4.             What
services were you offered upon your release from prison or jail?

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

5.             Were
you offered employment upon your release or as a condition of your
release.  Please explain.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

________________________________________________________________________________________________

6.             Were
you refused employment after your release?
_______  If so, what was the
reason given. ____________________

________________________________________________________________________________________________

7.             Do
you have any special skills or training for work? ________  If so, list your special skills or
training.

________________________________________________________________________________________________

________________________________________________________________________________________________

8.             List
five immediate things you feel that you needed that you did not receive when
you were released from prison that would have made a difference and deter your
returning to prison.  If this does
not apply to you, list five things that you did not receive from your transitional
facility that would have been helpful to you.

1.
________________________________________________________________________________________

2.
________________________________________________________________________________________

3.
________________________________________________________________________________________

4.             ________________________________________________________________________________________

5.
_________________________________________________________________________________________

9.             In
your opinion, what is the number one reason that ex-offenders return to jail or
the prison system after   being
released?

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

10.           In
your opinion, how important is counseling and psychological services to an
ex-offender returning to society?

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

11.           Additional
Comments:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________