| I. Global Risk Factors | | |
| a. Actuarial-RRASOR (high risk) or Static-99 (high-risk) | □ | □ |
| b. Multiple victim types | □ | □ |
| c. Young children targeted for substantial conduct | □ | □ |
| d. Sex offenses occurring during period supervision | □ | □ |
| e. Unplanned discharge | □ | □ |
| f. Offenses involving violence | □ | □ |
| GLOBAL FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| II. Diagnosis | | |
| a. Pedophilia or paraphilia DSM-IV-TR | □ | □ |
| b. Antisocial history, behaviors, or diagnosis | □ | □ |
| c. PCL-R high scores for those with ASPD traits | □ | □ |
| d. Sex offences occurring during period supervision | □ | □ |
| e. Drug or alcohol abuse (increases impulsivity) | □ | □ |
| f. Comorbid psychiatric disturbance (mood/psychotic) | □ | □ |
| DIAGNOSTIC FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| III. Social Skills Deficits | | |
| a. Poor social skills leading to associations with children | □ | □ |
| b. Inability to form peer sexual relationships | □ | □ |
| c. Targets lower functioning peers for sex | □ | □ |
| d. Long-term institutionalization, with resultant skills deficits and restrictive environment | □ | □ |
| e. Difficulty internalizing societal expectations | □ | □ |
| f. Lack of assertiveness, is a follower | □ | □ |
| g. Loneliness, lack of friends or other social support | □ | □ |
| SOCIAL SKILLS FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| IV. Behavioral Tendencies | | |
| a. Low frustration tolerance | □ | □ |
| b. Poor impulse control linked to sexual acting out | □ | □ |
| c. Difficulty in delaying immediate sexual gratification | □ | □ |
| d. Low self-esteem | □ | □ |
| e. Lack of assertiveness | □ | □ |
| f. Lack of compliance with supervision (probation/parole/conditional release) | □ | □ |
| BEHAVIORAL FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| V. Knowledge Levels | | |
| a. Little sexual knowledge | □ | □ |
| b. Poor understanding of laws related to sexual behavior | □ | □ |
| c. Unrealistic sexual expectations? | □ | □ |
| d. Lack of sexual experience with peers | □ | □ |
| KNOWLEDGE FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| VI. Treatment Progress | | |
| a. Reverting back to pretreatment attitudes | □ | □ |
| b. Poor response to treatment | □ | □ |
| c. Staff complacency, allowing negative behavior | □ | □ |
| d. Manipulative behavior in treatment | □ | □ |
| e. Treatment dropout or erratic attendance | □ | □ |
| f. Cognitive distortions present | □ | □ |
| TREATMENT PROGRESS FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| VII. Release Environment | | |
| a. Unstructured environment | □ | □ |
| b. Lack of mandated supervision | □ | □ |
| c. Inadequate community support | □ | □ |
| RELEASE FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |
| VIII. Acute Dynamic Risk Factors | | |
| a. Changes in social support (loss of family, involvement with negative peers) | □ | □ |
| b. Changes in substance abuse | □ | □ |
| c. Increase of sexual preoccupation | □ | □ |
| d. Negative emotional states | □ | □ |
| e. Change in attitude toward supervision | □ | □ |
| f. Changes in ability to cope (lowered), feeling overwhelmed | □ | □ |
| g. Changes to routine | □ | □ |
| h. Offender-specific characteristics (conflict with others, impulsive decision to quit job) | □ | □ |
| ACUTE FACTORS SUPPORT LIKELY RISK? | YES | NO |
| □ | □ |