Fresno, CA August Security Forms

CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION

Last Name, First Name, MI*

Other names you have been known by:

HOME ADDRESS (STREET NUMBER AND NAME, CITY, STATE, AND ZIP CODE):*

Email address:*

Date of Birth (Month, Day, Year)*

Date

Gender:*

MaleFemaleNon-Binary

Social Security Number (SSN)*

Contact Telephone Number*

State Bar #

State ID # or Driver's License #*

State*

Passport # (if no State ID/Driver's License)

Have you ever visited or had a personal relationship with any California Department of Corrections and Rehabilitation inmate or parolee for non-work related reasons?*

NoYes

Are you a former California State Prison inmate?*

NoYes

Have you ever been restricted or denied access to a State Prison?*

NoYes

Have you ever been convicted of a felony?*

NoYes

Please list the dates, counties & violations.*

Are you currently on probation/parole?*

NoYes

Do you have any pending or outstanding charges?*

NoYes

By signing this application, I attest that all of the information provided is true and correct. I acknowledge that prior written consent from the supervising agency is required for any parolee, probationer, or formerly incarcerated person to enter prison grounds. I further understand that, if approved, access is restricted to the designated area(s) and shall be under state employee escort unless otherwise authorized.

In accordance with the Privacy Act of 1974 (PL93-579), providing an SSN is optional. However, any omission of falsification may be cause for denial of access.

DEPARTMENT OF CORRECTIONS AND REHABILITATION

Individuals who are not employees of the California Department of Corrections and Rehabilitation (CDCR), but who are working in and around inmates who are incarcerated within California's institutions/facilities or camps, are to be apprised of the laws, rules and regulations governing conduct in associating with prison inmates, Title 15, Section 3285. The following is a summation of pertinent information when individuals not employed by the department (volunteers, media, contractors and their employees and dignitaries) come in contact with prison inmates.

1. Persons who are not employed by CDCR, but are engaged in work at any institution/facility or camp must observe and abide by all laws, rules and regulations governing the conduct of their behavior in associating with prison inmates. Failure to comply with these guidelines may lead to expulsion from CDCR institutions/facilities or camps.

SOURCE: California Penal Code (PC) Sections 5054 and 5058; California Code of Regulations (CCR), Title 15, Sections 3283, 3285, 3289, 3292 and 3415

2. CDCR does not recognize hostages for bargaining purposes. CDCR has a "NO HOSTAGE" policy and all prison inmates, visitors, nonemployees and employees shall be made aware of this.

SOURCE: PC Sections 5054 and 5058; CCR, Title 15, Section 3304

3. All persons entering onto institution/facility or camp grounds consent to a search of their person, property or vehicle at any time. Refusal by individuals to submit to a search of their person, property or vehicle may be cause for denial of access to the premises or restrictions to visiting or facility access.

SOURCE: PC Sections 2601, 5054 and 5058; CCR, Title 15, Sections 3173, 3267, 3288, 3289, and 3292.

4. Persons normally permitted to enter an institution/facility or camp may be barred, for cause, by the CDCR Secretary, Director of Division of Adult Institutions (DAI), Warden, Regional Parole Administrator and /or their designees.

SOURCE: PC Sections 2086, 5054 and 5058; CCR, Title 15, Sections 3283 and 3289

5. It is illegal for an individual who has been previously convicted of a felony offense to enter into CDCR institutions/facilities or camps without the prior approval of the Warden. It is also illegal for an individual to enter onto these premises for unauthorized purposes or to refuse to leave said premises when requested to do so. Failure to comply with this provision could lead to prosecution.

SOURCE: PC Sections 602, 4570.5 and 4571; CCR, Title 15, Sections 3173, 3283 and 3289

6. Encouraging and/or assisting prison inmates to escape is a crime. It is illegal to bring firearms, deadly weapons, explosives, tear gas, drugs or drug paraphernalia on CDCR institutions/facilities or camp premises. It is illegal to give prison inmates firearms, explosives, alcoholic beverages, wireless communication devices or components thereof, tobacco products, narcotics, or any drug or drug paraphernalia, including cocaine or marijuana.

SOURCE: PC Sections 2772, 2790, 4535, 4550, 4573, 4573.5, 4573.6, 4574, 4576 and 5030.1; CCR, Title 15, Sections, 3172.1, 3188 and 3292

7. It is illegal to give or take letters from prison inmates without the authorization of the Warden. It is also illegal to give or receive any type of gift and/or gratuities from prison inmates.

SOURCE: PC Sections 2540, 2541 and 4570; CCR, Title 15, Sections 3010, 3399, 3401, 3424 and 3425

8. In an emergency situation the visiting program and other inmate program activities may be suspended by the Warden or designee.

SOURCE: PC Sections 2086 and 2601; CCR, Title 15, Section 3383

9. For security reasons, volunteers, media, contractors, dignitaries and guests must not wear clothing that in any way resembles state issued prison inmate clothing (blue denim shirts, blue denim pants).

SOURCE: CCR, Title 15, Sections 3174 and 3349.2.3(g) (3) (B)

10. Interviews with SPECIFIC INMATES are not permitted. Conspiring with an inmate to circumvent policy and/or regulations constitutes a rule violation that may result in appropriate legal action.

SOURCE: CCR, Title 15, Section 3261.5

I HEREBY CERTIFY AND ACKNOWLEDGE I HAVE READ THE ABOVE AND FULLY UNDERSTAND THE IMPLICATIONS REGARDING MY CONDUCT AND ASSOCIATION WITH CDCR INMATES. I ALSO UNDERSTAND VIOLATION OF ANY OF THE ABOVE COULD RESULT IN EXPULSION FROM A CDCR INSTITUTION/FACILITY OR CAMP WITH THE POSSIBILITY OF CRIMINAL PROSECUTION.

Name and Title (Volunteer)*

STANDARDS OF CONDUCT FOR VOLUNTEERS

Ref. California Department of Corrections (CDCR), Department Operations Manual (DOM) 101090.9, Title 15, § 3401

1. Giving or receiving anything from any inmate that is not previously approved by the Community Resource Manager (CRM) is prohibited.
2. Contact with family members of inmates through the mail, by telephone, email or by personal contact without CRM approval is prohibited.
3. Do not give out personal telephone number, residence address or information that would assist inmates in contacting you.
4. Embracing, hugging or kissing inmates is not permitted.
5. Derogatory, discriminatory, or degrading remarks against any individual or faith group or religion is not acceptable at any time.
6. Coercion, intimidation, or embarrassment towards any inmate for the purpose of obtaining participation in voluntary activities is prohibited.
7. All security violations shall immediately be reported to custody staff and Community Resource Manager.

Printed Volunteer Name*

PREA POLICY INFORMATION FOR VOLUNTEERS AND CONTRACTORS PART A
CDCR 2301 (Rev. 05/20) Page 1 of 3

The Prison Rape Elimination Policy for the California Department of Corrections and Rehabilitation (CDCR) is explained on this informational sheet. As a volunteer or private contractor who has contact with CDCR offenders, it is your responsibility to do what you can, within the parameters of your current assignment, to reduce incidents of sexual violence, staff sexual misconduct, and sexual harassment and to report information appropriately when they are reported to you or when you observe such an incident. For purposes of this Policy, the word “staff” includes volunteers and private contractors.

Historical Information

Both the Congress and State Legislature passed laws, the Federal Prison Rape Elimination Act (PREA) of 2003, the Sexual Abuse in Detention Elimination Act, Chapter 303, Statutes of 2005, and most recently the United States, Department of Justice Final Rule; National Standards of 2012 to help prevent, detect, and respond to sexual violence, staff sexual misconduct, and sexual harassment behind bars. It is important that we, as professionals, understand all aspects of these laws and our responsibilities to help prevent, detect, and respond to instances by offenders and staff.

CDCR Policy

The CDCR policy is found in Department Operations Manual (DOM), Chapter 5, Article 44. PREA addresses five types of sexual offenses. Sexual violence committed by offenders against offenders encompasses: abusive sexual contact, non-consensual sex acts, and sexual harassment by an offender. Other sections covered by PREA include staff sexual misconduct towards an offender and staff sexual harassment towards an offender.

CDCR’s policy provides for the following:
• CDCR is committed to continuing to provide a safe, humane, secure environment, free from offender on offender sexual violence, staff sexual misconduct, and sexual harassment.
• CDCR maintains zero tolerance for sexual violence, staff sexual misconduct, and sexual harassment in its institutions, community correctional facilities, conservation camps, and for all offenders under its jurisdiction.
• All sexual violence, staff sexual misconduct, and sexual harassment is strictly prohibited.
• This policy applies to all offenders and persons employed by the CDCR, including volunteers and independent contractors assigned to an institution, community correctional facility, conservation camp, or parole.

Retaliatory measures against employees or offenders who report incidents of sexual violence, staff sexual misconduct, or sexual harassment as well as retaliatory measures taken against those who cooperate with investigations shall not be tolerated and shall result in disciplinary action and/or criminal prosecution. Retaliatory measures include, but are not limited to:
• Coersion.
• Threats of punishments.
• Any other activities intended to discourage or prevent staff or offenders from reporting incident(s).

Professional Behavior

Staff, including volunteers and private contractors are expected to act in a professional manner while on the grounds of a CDCR institution and while interacting with other staff and offenders. Key elements of professional behavior include:
• Treating everyone, staff and offenders alike, with respect.
• Speaking without judging, blaming, or being demeaning.
• Listening to others with an objective ear and trying to understand their point of view.
• Avoiding gossip, name calling, and what may be perceived as offensive or "off-color" humor.
• Taking responsibility for your own behavior.

Preventative Measures

You can help reduce sexual violence, staff sexual misconduct, and sexual harassment by taking various actions during the performance of your duties as a volunteer or private contractor.

The following are ways in which you can help:
• Know and enforce the rules regarding the sexual conduct of offenders.
• Be professional at all times.
• Make it clear that sexual activity is not acceptable.
• Treat any suggestion or allegation of sexual violence, staff sexual misconduct, and sexual harassment as serious.
• Follow appropriate reporting procedures and assure that the alleged victim is separated from the alleged predator.
• Never advise an offender to use force to repel sexual advances.

Detection

All staff, including volunteers and private contractors, is responsible for reporting immediately and confidentially to the appropriate supervisor any information that indicates an offender is being, or has been, the victim of sexual violence, staff sexual misconduct, or sexual harassment.

After immediately reporting to the appropriate supervisor, you are required to document the information you reported. You will be instructed by the supervisor regarding the appropriate form to be used for documentation.

You will take necessary action (i.e., give direction or press your alarm) to prevent further harm to the victim. Staff, including volunteers and private contractors, will request the victim does not: 1) Shower; 2) Remove clothing without custody supervision; 3) Use the restroom facilities; and 4) Consume any liquids.

I have read the information above and understand my responsibility to immediately report any information that indicates an offender is being, or has been, the victim of sexual violence, staff sexual misconduct, or sexual harassment.

Contact Telephone Number*

PART B shall only be completed by contractors who, in the course of their assigned duties, have contact with inmates.

Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, other institution?*

YesNo

Date of incident*

Date

Facility/County Name*

Have you ever 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

Date of incident*

Date

Case Number*

Have you ever been civilly or administratively found to have engaged in the activity described in question (2) above?*

YesNo

Date of incident*

Date

Case Number*

Have you ever received any disciplinary action as a result of allegations of sexual harassment of an inmate in a prison, jail, lockup, community confinement facility, or other institution?*

YesNo

Date of incident*

Date

Case Number*

As a contract employee, you have a continuing duty to promptly report, and you are required to notify your employer and the Appointing Authority of the Institution to which you are assigned if the answer to any of the above questions changes.

I hereby certify that there are no misrepresentations, omissions, or falsifications, and that all answers are true and correct. I understand and agree that if any material facts are discovered which differ from those facts stated by me on this form, my services to the California Department of Corrections and Rehabilitation will be discontinued and my contract employer will be notified.

In accordance with the California Department of Corrections and Rehabilitation (CDCR) California Code of Regulations, Title 15 Section 3406, and Department Operations Manual Section 33010.25.1, this form must be completed each time an employee becomes aware of a relative or person with whom the employee has/had a personal or business relationship who has been committed or transferred to the jurisdiction of the CDCR.

INSTITUTION/FACILITY/PROGRAM AREA*

WORK PHONE NUMBER (Include area code)

WORK ADDRESS

INMATE/YOUTH/PAROLEE NAME (Last, First, Middle Initial)*

DATE OF BIRTH (If known)

Date

IDENTIFICATION NUMBER*

INSTITUTION/FACILITY/REGION*

RELATIONSHIP TO EMPLOYEE (Relative, personal, or business)*

If the inmate/youth/parolee is transferred to your institution/facility/region, or is currently housed/assigned there, do you view his/her presence as conflicting with your employment caseload or responsibilities?*

YesNoN/A (I do not work at an institution/facility/region.)

If you are required to visit for work-related purposes (e.g., meeting, tour, temporary assignment) the institution/facility/region in which the inmate/youth/parolee is currently housed/assigned, do you view his/her presence as conflicting with your employment caseload or responsibilities?*

YesNo

Explanation:*

EMERGENCY NOTIFICATION INFORMATION CDCR 894 (Rev. 09/19)

Employees are responsible for ensuring this form is updated when changes occur. The person(s) to be notified in case of emergency should be over the age of 18.

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (over the age of 18)

NAME (Last, First, Middle)*

RELATIONSHIP*

HOME ADDRESS (STREET NUMBER AND NAME, CITY, STATE, AND ZIP CODE)*

Contact Telephone Number*

ALTERNATE PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (over the age of 18)

NAME (Last, First, Middle)*

RELATIONSHIP*

HOME ADDRESS (STREET NUMBER AND NAME, CITY, STATE, AND ZIP CODE)*

Contact Telephone Number*

MEDICAL INFORMATION

PERSONAL PHYSICIAN'S NAME*

PHONE NUMBER*

MEDICAL PLAN NAME*

MEDICAL PLAN CARD NUMBER*

MEDICAL FACILITY NAME AND LOCATION*

SPECIAL MEDICAL CONDITIONS (ALLERGIES, ETC.)

SPECIAL INSTRUCTIONS

SUPPLEMENTAL APPLICATION FOR ALL CDCR EMPLOYEES
CDCR 1951 (Rev. 07/18)

All applicants seeking employment with the California Department of Corrections and Rehabilitation (CDCR) must complete this form, as set forth in the Department Operations Manual (DOM), Chapter 3, § 31060.17. This questionnaire will supplement the information provided on your application/resume and will be considered during the selection process.

Complete ALL items. If a question does not apply, enter “DNA.” If appointed to any position within CDCR, you will be fingerprinted for the purpose of obtaining a criminal record check from the Department of Justice. Note: Sections A and B are not required for Peace Officers promoting to higher Peace Officer classifications.

Last 4 of SSN*

Have you ever been arrested for any alleged violation of the law?*

NoYes

Did any charges rise to the level of a felony conviction?*

NoYes

List all arrests or citations for felony and/or misdemeanor offenses, regardless of the final disposition, dates, and locations of the arrests or citations (exclude parking or minor traffic citations). All arrests and citations must be listed, including any that may have been deleted or expunged from your official records or did not result in formal charges. Vehicle code violations resulting in an arrest must be reported, including those not rising to the level of a felony or misdemeanor. In addition, list all citations for any alleged violations of a professional licensure or regulatory law for which the license or law is related to the position for which you are applying.

Offense #1

City/State*

Month/Year*

Specific Charge*

Disposition (Outcome)*

Offense #2

City/State

Month/Year

Specific Charge

Disposition (Outcome)

Offense #3

City/State

Month/Year

Specific Charge

Disposition (Outcome)

Offense #4

City/State

Month/Year

Specific Charge

Disposition (Outcome)

Have you ever been refused a driver’s license, had one revoked, suspended, restricted, placed on probation or negligent operator status?*

NoYes

Offense #1

City/State*

Month/Year*

Specific Charge*

Disposition (Outcome)*

Offense #2

City/State

Month/Year

Specific Charge

Disposition (Outcome)

Offense #3

City/State

Month/Year

Specific Charge

Disposition (Outcome)

Have you ever been confined in a prison, jail, lockup, community confinement facility, or other institution (as defined in 42 U.S.C. 1997)?*

NoYes

Complete the following.

Confinement #1

Place of Confinement*

Specific Charge*

Dates of Confinement*

Confinement #2

Place of Confinement

Specific Charge

Dates of Confinement

Confinement #3

Place of Confinement

Specific Charge

Dates of Confinement

Have you ever been the subject of any judicial or non-judicial disciplinary actions (Article 15 of the Uniform Code of Military Justice) while in the military, National Guard, or military reserves?*

NoYes

Military Offense #1

Place and Date of Offense*

Specific Charge*

Disposition (Outcome)*

Military Offense #2

Place and Date of Offense

Specific Charge

Disposition (Outcome)

Have you previously worked for a correctional institution employer including prison, jail, lock-up, community confinement facility, juvenile facility, or other correctional institution/facility?*

NoYes

List all previous correctional institution employers for whom you have worked. Include any prison, jail, lock-up, community confinement facility, juvenile facility, or other correctional institution/facility, regardless of dates of employment. If additional space is needed, please use the back of this form. Prior to appointment to any position within the CDCR, the previous employers will be contacted to verify the above responses.

Employer #1

Name and Address of Employer*

Your Classification*

In your assignment, did you have contact with inmates?*

NoYes

Employer #2

Name and Address of Employer

Your Classification

In your assignment, did you have contact with inmates?

NoYes

Employer #3

Name and Address of Employer

Your Classification

In your assignment, did you have contact with inmates?

NoYes

Are you aware of any relative or person with whom you have or have had either a personal or a business relationship with currently committed (incarcerated) or transferred (paroled) to the jurisdiction of CDCR?*

NoYes

Person #1

Name*

CDCR# (if known)*

Relationship*

Place of Incarceration or parole*

Person #2

Name

CDCR# (if known)

Relationship

Place of Incarceration or parole

Person #3

Name

CDCR# (if known)

Relationship

Place of Incarceration or parole

NOTICE OF RIGHT TO REQUEST REASONABLE ACCOMMODATION
CDCR 859 (10/23)

California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) employees, applicants, or volunteers who have a disability or medical condition that prevents them from performing one or more of their job or volunteer duties have the right to request reasonable accommodations that enable them to perform all essential functions.

A Reasonable Accommodation (RA) is any modification or adjustment to a job and/or the work environment that is effective in enabling an employee, applicant, or volunteer to perform the essential functions of the job they hold or desire. RAs may include, but are not limited to, providing assistive aids and services such as qualified interpreters, job restructuring, modified schedule, additional training, paid or unpaid leave, or a medical transfer/demotion.

RAs may be requested verbally, in writing, or by submitting a Request for Reasonable Accommodation (CDCR 855) form to the hiring authority, manager, supervisor, or Return to Work Coordinator. This acknowledgement form shall be retained in your Official Personnel File (OPF).

I acknowledge I have received and read this form and understand the notification about the right to request reasonable accommodations at any time.

SUPPLEMENTAL APPLICATION FOR ALL CDCR EMPLOYEES
CDCR 1951 (Rev. 07/18)

In accordance with the CA Code of Regulations (CCR), Title 15, Crime Prevention and Corrections, § 3411, if an employee is subsequently arrested or convicted, the employee must promptly notify the institution head or deputy/assistant director. Pursuant to Section CCR Title 15 § 3406, and DOM § 33010.25.1, if an employee becomes aware that any relative or person with whom the employee has or has had a personal or business relationship has been committed to or transferred to the jurisdiction of CDCR, the employee must report the matter in writing to the institution head or deputy/assistant director. CA Penal Code § 4571 prohibits any person who has been previously convicted of a felony and confined in any State prison in this State, to come upon the grounds of any prison, forestry camp, or where any custodial inmates are located, without the consent of the Warden or other officer in charge of that facility.

I hereby certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and that all statements and answers are true and correct. I understand and agree that if any material facts are discovered which differ from those facts stated by me on my employee application, this supplemental application, during my interview, or at any time prior to employment with CDCR, I may not be offered the job.

Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from the facts I furnished before beginning employment, I may be rejected on probation and/or disciplined, up to and including dismissal from State service.

Signature*

Date*

Date

Are you on parole?*

YesNo

Parole Unit and District*

Parole Agent*

Contact Number*

Date of Receipt*

Supervised Person Full Name*

CDCR#*

Lifer or High Notoriety Case*

Risk Score (CSRA/Static 99R)*

Commitment Offense*

Requested Institution*

Clearance Request

No

Program Name*

Summary of Parole Adjustment*

Upload a color copies of both sides of your ID*

BACKGROUND SECURITY CLEARANCE APPLICATION CONFIDENTIAL - FOR OFFICIAL USE ONLY - CDCR 2311

PRIMARY LAWS, RULES, AND REGULATIONS REGARDING CONDUCT AND ASSOCIATION WITH STATE PRISON INMATES

PREA POLICY INFORMATION FOR VOLUNTEERS AND CONTRACTORS PART B

Duty to Report

INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION

EMPLOYEE INFORMATION

INMATE/YOUTH/PAROLEE INFORMATION

Request for Institutional Gate Clearance