New Castle, IN Security Forms

By the person's signature on this form, he/she is aware of and has agreed to a criminal history and warrants check through the Indiana Department of Correction as part of a background investigation. This person is aware that the information received will be in the determination of approval or denial of employment, volunteer and visitation, and that this information will be shared on a need-to-know basis. Please print clearly and provide the most accurate information.

Facility

Reason

First Name*

Last Name*

Middle Name

Maiden Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Previous Address

Previous Address(es)

Street Address Line 2

CityState

Zip Code

Date of Birth*

Date

State of Birth*

Social Security Number*

Driver's License Number*

State of Driver's License*

Sex*

Race*

Weight*

Height*

Hair*

Eyes*

Felony Conviction*

YesNo

Felony Explanation*

Employer

Employer Address

Address

Street Address Line 2

CityState

If born outside USA, how old were you when you arrived in the country?

If born outside the USA, were your parents in the US Military at the time of birth?

YesNo

Passport Number

Green Card Number

Name*

Date

The following Indiana Statutes are brought to your attention. As a person desiring to enter a correctional facility, either as an employee or for other approved purposes, it is important to understand the content of these laws.

Indiana Code states:
(b) Except as provided in subsection (d), a person who, without the prior authorization of the person in charge of a penal facility or juvenile facility knowingly or intentionally:
(1) delivers, or carries into the penal facility or juvenile facility with intent to deliver, an article to an inmate or child of the facility;
(2) carries, or receives with intent to carry out of the penal facility or juvenile facility, an article from an inmate or child of the facility; or
(3) delivers, or carries to a worksite with intent to deliver, alcoholic beverages to an inmate or child of a jail work crew or community work crew; or
(4) possesses in or carries into a penal facility or a juvenile facility:
(A) a controlled substance; or
(B) a deadly weapon;
commits trafficking with an inmate, a class A misdemeanor.

(c) If the person who committed the offense under subsection (b) is an employee of:
( 1) the department of correction; or
(2) a penal facility;
and the article is a cigarette or tobacco product (as defined in Indiana Code), the court shall impose a mandatory five thousand dollar ($5,000) fine under Indiana Code, in addition to any term of imprisonment imposed under Indiana Code.

(d) The offense under subsection (b) is a Level 5 felony if the article is:
(1) a controlled substance; or
(2) a deadly weapon; or
(3) a cellular telephone or other wireless or cellular communications device.

A person who commits a Class A misdemeanor shall be imprisoned for a fixed term of not more than one (1) year; in addition, he/she may be fined not more than five thousand dollars ($5,000). A person who commits a Level 5 felony shall be imprisoned for a fixed term of four (4) years, with not more than four (4) years added for aggravating circumstances or not more than two (2) years subtracted for mitigating circumstances. In addition, he/she may be fined not more than ten
thousand dollars ($10,000).

It is a Class C infraction for a person to furnish an alcoholic beverage to a person confined in a penal facility. It is unlawful, also, for a person who has charge of a penal facility to knowingly permit a prisoner confined within his/her jurisdiction to receive an alcoholic beverage unless it has been prescribed by a physician as medicine for the prisoner or unless it is distributed as sacramental wine for a religious purpose by a minister, priest, or rabbi.

A person who commits a Class C infraction may be fined not more than five hundred dollars ($ 500).

I, the undersigned, have read and understand the above statutes. I recognize the potential danger of contraband or prohibited property of any nature entering or leaving the I do hereby express my willingness to submit to a thorough search of my person, articles in my possession or any vehicle that I may operate on the grounds of the facility at any time that the Facility Head or designee authorizes. Such searches may include work areas, post assignment, and my living quarters, if on State property.

I understand that refusal to submit to such a search shall be cause to be refused entrance to the facility or to be removed from a facility and may constitute grounds for disciplinary action or referral for prosecution.

Mandatory Pre-Service PREA Questions

As part of a background check required by the Prison Rape Elimination Act 28 CFR 115.17/317, you are required to answer the following questions before having contact with incarcerated individual:

Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?*

YesNo

Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?*

YesNo

Have you been civilly or administratively adjudicated to have engaged in the activity described In number 1 and 2 above?*

YesNo

Have you ever had a substantiated finding of sexual harassment of an incarcerated individual, resident or student in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?*

YesNo

I affirm that the answers I have provided are accurate and truthful. I understand that material omissions regarding such and a misconduct, permanent or the gate provision closure of to all materially IDOC false facilities. I information, also undershall stand result I in have my a dismissal continuing or affirmative removal from duty to the disclose facility/ any program such misconduct.

Please check one that applies to your position with the Indiana Department of Correction:*

Contract EmployeeVolunteerNon-DOC Crew SupervisorState Employee

INDIANA DEPARTMENT OF CORRECTION

Acknowledgment of Receipt of Training & Brochures "Sexual Assault Prevention"

This receipt acknowledges that on this date I received training (and understand said training) from the Indiana Department of Correction regarding the Prison Rape Elimination Act (PREA} and Department of Correction Policy 02-01-115, "Sexual Abuse Prevention." Additionally, I have been provided with a copy of the Department of Correction Brochure, "Sexual Assault Prevention" and a copy of any facility brochures/documents relating to sexual abuse prevention and reporting. If I have not already been provided with a copy of these documents.

Also, my signature indicates that I understand that the Department of Correction maintains a Zero {0) Tolerance for sexual misconduct, abuse and assault Involving staff and/or Incarcerated individuals/students. I understand that any sexual contact, including physically touching, verbal or written comments, sexual harassment, etc., between a staff person, contractor, volunteer and/or incarcerated Individual/ student is strictly prohibited and may be In violation of IC 35-44.1-3-10, Sexual Misconduct. which states that a service provider who knowingly or intentionally engages In sexual intercourse or other sexual conduct (as defined by IC 35-31.5-2-221.5) with a person who is subject to lawful detention or lawful supervision commits sexual misconduct a Level 5 felony. The Department of Correction shall terminate from employment any staff person who commits any sex act while on duty and/or while in a Department facllit; office; with or in the presence of an incarcerated individual/student. Additionally, the Department will pursue criminal prosecution of any staff person who engages in sexual misconduct.
Further, I understand that:

1. As with all Department of Correction Policies and Procedures, it is my responsibility for maintaining familiarity with, and adherence to, this policy and its procedures.
2. Questions regarding this policy and its administrative procedures may be addressed to my immediate supervisor.
3. Procedures regarding subjects covered by this policy, but not limited to this policy, are available for my information and review through my department. It is my responsibility to comply with Department of Correction and facility policies, procedures and directives.

I realize that once I am accepted as an Indiana Department of Correction Volunteer, I hereby waive and release any and all rights or claims of any kind that may exist or accrue in the future against the State of Indiana, Department of Corrections, The GEO Group, Inc., its personnel or its agents aa a result of my duties and responsibilities which I will undertake as a volunteer. I am voluntarily signing this waiver.

Signature of Applicant*

Please upload a copy of the front of your driver's license:*

INDIANA DEPARTMENT OF CORRECTION

STATEMENT OF TRAFFICKING LAWS AND AUTHORIZATION FOR SEARCH