Chillicothe, OH Security Forms

Chillicothe, OH Security Forms

Volunteer/Contractor/Intern Emergency Information
Name*
Last 4 digits of Drivers License #*
Current Residence*
City*
State*
Zip Code*
Birth Date*

MonthDayYear
Date
Email Address*
Home Phone
Please enter a valid phone number.
Cell Phone*
*In the event of an emergency where driving directions are needed to your home, the address listed above will be used to through the internet. run "driving directions" using a mapping service
List 3 Persons To Notify In The Event Of An Emergency:
Print Name for Person 1*
Relationship*
Primary Phone Number*
Please enter a valid phone number.
Alternate Number
Please enter a valid phone number.
Address*
City*
State*
Zip*
Print Name for Person 2*
Relationship*
Phone Number*
Please enter a valid phone number.
Address*
City*
State*
Zip*
Print Name for Person 3*
Relationship*
Phone Number*
Please enter a valid phone number.
Address*
City*
State*
Zip*
Do You Wear a Medical Tag?*

YesNo
If Yes, Please Explain*
Family Doctor Name*
Doctor's Phone Number*
Please enter a valid phone number.
Model of Car 1*
Plate#*
Model of Car 2
Plate
Staff Nexus

Definition of Staff Nexus -An employee, volunteer or contractor who has any contact and/or relationship with an inmate or offender who is currently under supervision of DRC.

Notice: If the relationship changes you are required to complete a new nexus form immediately.
Name*
Job Title
Your OAKS Number
Volunteer Type
Your Current Work Location
COMPLETE ONLY ONE SECTION BELOW (I, II OR III)
I - NO NEXUS Definition

I state that, to the best of my knowledge, I have no nexus connection, affiliation, or relationship to any inmate/offender currently under the supervision of the the Ohio Department of Rehabilitation and Correction. I understand that should I become aware of such a relationship I am required to notify my Managing Officer/ APA Regional Administrator the next business day.
II - NEXUS - REQUESTING NO CONTACT Definition

I do have a nexus I am required to report, but I do not wish to correspond, visit, send funds/packages or communicate with them while they are incarcerated or on under community supervision.
III - NEXUS - REQUESTING CONTACT Definition

I have a nexus with the inmate/offender listed below who is currently incarcerated in the ODRC or under the supervision of the APA and I wish to maintain contact with them.
NEXUS Select One*

NO NEXUSNEXUS - REQUESTING NO CONTACTNEXUS - REQUESTING CONTACT
Offender Name*
Offender Number*
Conflict Anticipation*

I do not anticipate professional conflict if the individual remains in the same prison/APA region.I anticipate a professional conflict if the individual remains in the same prison/APA region.
Please Note: In some cases, inmates with certain medical, mental health, classification, security, supervision or other needs will required the inmate to be kept in a certain prison/region. In situations where inmates cannot be moved for these reasons, requests to not work in the same facility/region with the inmate cannot be accommodated.
Please describe your relationship and the reason you anticipate a professional conflict:*
Offender Name*
Offender Number*
Please describe your relationship and the purpose and extent of the contact:*
Department of Rehabilitation and
Correction
Prison Rape Elimination Act
Contractor/Volunteer/lntern Training
Acknowledgement Formdgement Form
I acknowledge that I have received and understand the training on my responsibilities under the Ohio Department of Rehabilitation and Correction's Prison Rape Elimination Act Policies (79-ISA-01, 02, 03, 04, 05) to include the following:

1. The Department's zero-tolerance for sexual abuse
2. The Department's zero-tolerance for sexual harassment
3. How to report sexual abuse and sexual harassment
4. Sexual abuse and sexual harassment prevention
5. Sexual abuse and sexual harassment detection
6. How to respond to sexual abuse and sexual harassment
7. The legal prohibition on any sexual activity with inmates
8. The identifiers of possible sexual assault victims
9. Sexual assault prevention strategies
Contractor/Volunteer/Intern Supplemental Questionnaire
Last 4 Digits of SSN*
Have you ever been convicted of O.R.C. 2909.22,2909.24, and/or 2909.29; Soliciting or providing support for an act of terrorism, terrorism, or money laundering in support of terrorism?*

YesNo
Have you ever been accused of an inappropriate or unauthorized relationship in a prison, jail, lockup, community confinement facility, juvenile facility or other institution?*

YesNo
If you answered yes to the above question, please indicate the Employer, Dates of employment, Allegation, and Outcome. lf no, write N/A.*
Have you ever been accused of sexual abuse or resigned from employment during a pending investigation of an allegation of sexual abuse?*

YesNo
If you answered yes to the above question please indicate the Employer, Dates of employment, Allegation, and Outcome. If no, write N/A.*
Have you ever been accused of sexual harassment?*

YesNo
If you answered yes to the above question please indicate the Employer, Dates of employment, Allegation, and Outcome. If no, write N/A.*
Have you ever been civilly or administratively adjudicated or 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
If you answered yes to the above question please indicate the Location of adjudication or conviction, Date of adjudication and/or conviction, Allegation, and Outcome. If no, write N/A.*
Have you ever been accused of or been convicted of O.R.C. 2921.36; illegal conveyance of weapons, drugs, or other prohibited items onto the grounds of a detention facility or institution?*

YesNo
If you answered yes to the above question please indicate the Employer, Date of employment, Allegation and Outcome. If no, write N/A.*
Have you ever knowingly accessed confidential personal information in violation of a rule of a state agency; or knowingly used or disclosed confidential personal information in a manner prohibited by law?*

YesNo
If you answered yes to the above question please indicate the Employer and/or location, Location, Date, and Outcome. If no, write N/A.*
Signature*

Clear
Date*

MonthDayYear
Date
Media Permission Grant/Refusal
Media Permission Grant/Refusal

I hereby grant permission to the Department of Rehabilitation and Correction to make use of my name, comments, still or motion pictures, voice recordings and/or video tape of me for any legitimate purpose, including publication in news media and for professional and institutional purposes. I hereby release and hold harmless the Ohio Department of Rehabilitation and Correction, its agents and servants, from any and all claims for damage for libel, slander, invasion of the right of privacy or any other claim, based on the use of said material. The above consent is give by me freely and voluntarily without any promises, threats, or duress.I decline to be interviewed.
Print Name*
Print Name*
Decline Date*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Chillicothe, OH Security Forms

List 3 Persons To Notify In The Event Of An Emergency:

COMPLETE ONLY ONE SECTION BELOW (I, II OR III)

I - NO NEXUS Definition

II - NEXUS - REQUESTING NO CONTACT Definition

III - NEXUS - REQUESTING CONTACT Definition