Columbus, OH North Security Forms 2026

Columbus, OH North 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.Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
*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.Format: (000) 000-0000.
Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*
City*
State*
Zip*
Print Name for Person 2*
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*
City*
State*
Zip*
Print Name for Person 3*
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*
City*
State*
Zip*
YesNo
If Yes, Please Explain*
Family Doctor Name*
Doctor's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Model of Car 1*
Plate#*
Model of Car 2
Plate
Staff Nexus

Definition of Nexus - An employee, volunteer or contractor who has any contact and/or relationship with an incarcerated person who:
- Is currently Incarcerated under the supervision of the Department or Rehabilitation and Correction
- Is currently on parole under the supervision or the Department or Rehabilitation and Correction
- Was recently released from a DRC facility (within the last 5 years)
- Was recently released from parole under DRC Supervision (within the last 5 years)
A Nexus would include but not be limited to the following examples:
- If you have been on an offender's visit list
- If you have ever placed money on an incarcerated person's/supervisee's books
- If you have ever communicated with an incarcerated person/supervisee on electronic messaging.
- If you have ever made phone calls to or received phone calls from an incarcerated person/supervisee.
I understand if my relationship status changes or I transfer to a different work location, I am immediately required to complete a new nexus form and submit it to my Managing Officer/APA Regional Administrator for approval.
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.
NO NEXUSNEXUS - REQUESTING NO CONTACTNEXUS - REQUESTING CONTACT
Offender Name*
Offender Number*
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*
YesNo
YesNo
If you answered yes to the above question, please indicate the Employer, Dates of employment, Allegation, and Outcome. lf no, write N/A.*
YesNo
If you answered yes to the above question please indicate the Employer, Dates of employment, Allegation, and Outcome. If no, write N/A.*
YesNo
If you answered yes to the above question please indicate the Employer, Dates of employment, Allegation, and Outcome. If no, write N/A.*
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.*
YesNo
If you answered yes to the above question please indicate the Employer, Date of employment, Allegation and Outcome. If no, write N/A.*
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
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:

Columbus, OH North 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