EM 03 Electronic Monitoring Health and Safety Check

Name PRN

ELECTRONIC MONITORING HEALTH AND SAFETY CHECKLIST

This form is to help a report writer identify any health and safety risks for the occupants who reside at the proposed
address, and to provide information to the probation officers and field officers who will be required to visit the address.
This information must be entered in Eagle within 24 hours of the visit, and documented appropriately in PAC reports
and OMCs, IOMS case notes, IOMS alerts, CEP process, EM Bail Suitability Report, and if applicable information
sharing with Police.

Proposed EM Address * Contact Number

* Check the address on the NZ Post website (https://www.nzpost.co.nz/tools/address-postcode-finder) to ensure

accurate address details are entered into IOMS and Eagle.

Remote feasibility check

Has a remote feasibility check been completed for this address? Guidance on how to complete this can be
found in the practice centre.

Address has passed remote feasibility check Address has failed remote feasibility check *

* If a property has failed the remote check then the address may not be suitable for electronic monitoring. Consider
speaking to EM Tech Support about this property and booking an onsite feasibility check through Eagle

Description of proposed building/property

(e.g., is it a flat/apartment? Where will the person be sleeping – in the house/sleepout/garage? How accessible is
the address? Is it a shared driveway or on an unsealed road? Are there any obstacles to accessing the address? Are
door codes required? Is there cell phone coverage in the area? Would someone have trouble accessing the property
in the dark or in bad weather?)

Is the person and the occupants aware of what the boundary for the address would be?

Discuss boundary of the property with the person being sentenced and occupants of the address -

Are there any of the following at the address?

Animals (e.g., dogs) Aggressive people Gang paraphernalia

Weapons Access issues Drug paraphernalia
Other notes:

What power supply does the address have?

Billed Power Card Power Other *

*Note: Connections via generators, wind, solar or other types of power can be approved as long as they guarantee constant
supply and provide standards compliant power outlets. Equipment requires 230V 50Hz AC 10A wall sockets per AS/NZS
3112:2000 for the wall chargers

Location: Probation Practice Centre – Forms and Documents Electronic Monitoring

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 EM 03 Electronic Monitoring Health and Safety Check

Occupants’ safety checklist

Occupants’ names:

Prompts for elicit information - please use your professional judgement with your approach

How long have you known the person being sentenced

and/or bailed?

What is your relationship to them?

Have you previously lived together?

Have they ever behaved in a violent or threatening

manner toward you, or toward anyone else including
children; either verbally, physically, emotionally, or
sexually?
Have they ever intentionally caused damage to your
property, or to property in the home (for example,
punching or kicking walls or doors)?
Have you ever feared for your safety as a result of their
actions?

Have the Police ever been called to your home, or to

any previous address you have shared with them? If
so, when and in what circumstances?
Are you aware of any protection order in place naming
the person?

Do they or any other person in the household have any

gang associations?

Are you aware of any issues concerning them and any

person in the home, that are likely to lead to distress or
aggression (for example, relationship issues or house
rules)?
Are Oranga Tamariki involved with any person in the
household?

Are any firearms kept on the premises?

Are there any other safety issues we haven’t covered

that you think I should know about?

Location: Probation Practice Centre – Forms and Documents Electronic Monitoring

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 EM 03 Electronic Monitoring Health and Safety Check

Any other comments:

Has the information gathered in this form been entered in the appropriate systems?

Health and Safety information entered in Eagle within 24 hours of site visit Yes

Documented as appropriate in PAC report and OMC, CEP, EM Bail Suitability Report IOMS
Yes
case notes, IOMS alerts

Report writer details

Report Writer Name Date

Signature

Location: Probation Practice Centre – Forms and Documents Electronic Monitoring

In Confidence Ara Poutama Aotearoa v.3.0 updated July 2022 Page 3 of 3