#3. SEXUAL MISCONDUCT 03-506.pdf

DOC 03-506 (Rev. 03/04/22) Page 1 of 2 DOC 530.100, DOC 810.800

SEXUAL MISCONDUCT AND INSTITUTIONAL

EMPLOYMENT/SERVICE DISCLOSURE

PART 1 - To be completed prior to appointment

Full name (print):

Federal Prison Rape Elimination Act (PREA) standards require that the Department of Corrections seek disclosure of sexual misconduct from prospective employees, contract staff, and volunteers at the time of hire and whenever the person is considered for promotion.

It is also necessary that all Department of Corrections employees, contract staff, volunteers, and prospective personnel be carefully screened prior to appointment. This includes a review of all prior employment/service with employers that house or provide services to individuals, youths, vulnerable persons, or others in an institutional setting such as prison, jail, lockup, community confinement facility, juvenile facility, or other facility as defined under 42 USC 1997 (i.e., facility for the mentally, physically, intellectually disabled, residential care or treatment facility for juveniles, facility that provides skilled nursing, intermediate or long-term care, or custodial or residential care).

AN INSTITUTION IS: Any facility or institution which is owned, operated, managed by, or provides services on behalf of the state or federal Government, or political subdivision of a state (i.e., county, city, or town).

Please note - An “institutional setting” does not include employment in privately-owned and operated facilities such as nursing homes, where the sole connection to the state is a state license to operate the establishment unless state and/or federal government agencies contract with the facility or its parent company to house individuals.

SEXUAL MISCONDUCT DISCLOSURE

Have you ever engaged in sexual abuse in a prison, jail lockup, community confinement facility, juvenile facility, or institutional setting (as defined above)? No Yes

Have you ever been civilly or administratively adjudicated (there was a formal finding and a judgment or decision was rendered in a civil or administrative proceeding) or otherwise found to have engaged or attempted to engage in sexual abuse/assault in any setting?

No Yes

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?

No Yes

Have you been the subject of substantiated allegations of sexual abuse or sexual harassment or resigned during a pending investigation of alleged sexual abuse or sexual harassment?

No Yes

Have you ever engaged in any other incident of sexual harassment or sexual misconduct not already addressed above? No Yes

If you answered YES to any of the above questions, please explain below or attach additional sheets/information if needed.

Acknowledgment and Release All answers and statements are true and complete to the best of my knowledge. I understand that a background check will be conducted including, but not limited to, prior employment and contract/volunteer service. I understand that, if hired, untruthful or misleading answers or deliberate omissions may be cause for rejection of my application, removal of my name from eligible registers, or dismissal, if employed or serving as a contract staff or volunteer. By signing this form, I am acknowledging that the information provided above is accurate and complete and giving my authorization to the release of my information.

Signature: Date: