COOK COUNTY SHERIFF’S OFFICE

NON-EMPLOYEE/VOLUNTEER APPLICATION

(FCN-37) (MAY 25)

APPLICANT INFORMATION

Type of Request:

NEW RENEWAL CLINICAL ROTATION TEMPORARY- UNDER 30 DAYS OTHER: _____________________ Applicant's Name: Date of Birth: Last 4 Digits of SSN:

Address (Street, City, State, ZIP Code):

Home Phone: Work Phone: Cell Phone:

Height: Weight: Hair Color: Eye Color:

Driver’s License/ State Identification Number: Email Address:

Emergency Contact (Name): Relationship:

Address (Street, City, State, ZIP Code): Emergency Contact Phone Number:

Department Applicant is Requesting to Volunteer With:

CCSPD CSD CCDOC EXECUTIVE OFFICE OTHER: ___________________________________

N/A SPONSOR/VOLUNTEER’S AGENCY (If applicable) Sponsor/ Volunteer Agency Name: Sponsor/ Volunteer Agency Supervisor: Cell Phone:

CRIMINAL/CIVIL HISTORY (If you answered YES to any questions below, explain on back) Have you ever been arrested?

YES NO If YES, Date(s): ___________________

Have you ever been convicted of a misdemeanor or felony?

YES NO If YES, Date(s): ___________________

Do you have a criminal case pending against you?

YES NO If YES, Date(s): ___________________

Do you have a civil case pending against you?

YES NO If YES, Date(s): ___________________

Do you have a family member/friend in Sheriff’s Office custody?

YES NO If YES, provide name(s) and date(s)

Have you ever visited an individual in custody?

YES NO If YES, provide name(s) and date(s) In the past 24 months, have you been in contact with any individual in custody (including by phone or mail)?

YES NO If YES, provide name(s) and date(s)

In the past 24 months, have you ever deposited money into the trust account of an individual in custody?

YES NO If YES, provide name(s) and date(s)

By signing below, I certify that (Initial lines):

1. The Cook County Sheriff's Office Code of Conduct Agreement and PREA Acknowledgement Form have been read, are understood, and signed.

2. I understand that any violation of the Code of Conduct stipulations or PREA restrictions may result in revocation of privileges and may include criminal charges.

3. If applicable, the non-employee identification issued by the Cook County Sheriff’s Office shall remain the property of the Sheriff’s Office.

4. I understand there are inherit risks involved with entering a secure facility which houses subjects in custody for pending criminal charges or county sentences. I may observe, experience, or encounter offensive and/ or vulgar conduct by IICs.

5. I authorize the Cook County Sheriff's Office to run a complete background investigation, including criminal history, fingerprint inquiry, if required, and understand I must pass that check to participate in the volunteer opportunity.

Applicant Signature: Date:

Have you been known by any other names? YES NO

Other name(s), if applicable:

Position/Title:

Sex Assigned at Birth

MALE FEMALE

TRANSGENDER WOMAN/TRANSFEMININETRANSGENDER MAN/TRANSMASCULINEGender Identity

MAN WOMAN NONBINARY/GENDER NON-CONFORMING OPTION TO FILL IN

Sex and gender information is collected to help identify the applicant for the purposes of completing a background check. The Sheriff’s Office considers such information sensitive and will not share it with third parties except when required by law or regulation.

Anticipated Start Date Anticipated End Date

(FCN-37) (MAY 25)

VOLUNTEER STATEMENT

Please indicate why you would like to volunteer with/for the Cook County Sheriff’s Office and what it is you are seeking from this opportunity:

CRIMINAL/ CIVIL HISTORY CONTINUATION

If you answered YES to any of the criminal/civil history questions, explain below:

(FCN-37) (MAY 25)

APPLICANT INFORMATION

Applicant Name: Date of Birth:

AGREEMENT

WAIVER: In consideration of being provided an opportunity to volunteer my services with the Cook County Sheriff’s Office and its departments, acceptance of which is hereby acknowledged, I, for myself, my heirs, executors, successors, and assigns, do expressly release and forever discharge the Sheriff of Cook County, Thomas J. Dart, the Sheriff’s Office and Cook County, Illinois, in their individual and official capacities and their present and future elected officials, officers, directors, employees, attorneys, agents, servants, representatives, insurers, and anyone else acting or purporting to act on their behalf, from all demands, claims, actions and damages raised in any action, whether known or unknown, resulting from or arising out of this volunteer opportunity with the Sheriff’s Office. I expressly release their agents, employees, officers, directors and other volunteers or participants in the programs from any and all claims, including but not limited to those resulting in physical or psychological injury, personal injury, accidents or illness, including death, property loss, damages or emotional loss I may suffer that may have been caused by or related to my voluntary participation, including but not limited to travel to, from and/or during my participation with the programs offered at the Sheriff’s Office and its various departments. This waiver shall commence from the date of execution of the Agreement, but specifically excludes any claims that may have occurred or accrued prior to execution of the Agreement.

ASSUMPTION OF RISKS: I am aware the Sheriff’s Office is a law enforcement agency and that volunteer service with the Sheriff’s Office carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries.

The specific risks vary from one activity to another, including but not limited to exposure to a penal institution, minor injuries such as scratches, bruises, stings and sprains, or major injuries, such as eye injury or loss of sight, joint or back injuries, heart attacks and concussions, or catastrophic injuries, including paralysis or death.

I have read the previous paragraphs, and I know, understand, and appreciate these and other risks that are inherent in my participation in volunteer services with the Sheriff’s Office, and I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

LIABILITY: I understand and agree that I shall be solely responsible for any liabilities arising from my own recklessness, gross negligence, bad faith, or willful misconduct on my part.

ACKNOWLEDGEMENT OF UNDERSTANDING: I have read this Agreement, fully understand its terms, and understand that I am giving up substantial rights, INCLUDING MY RIGHT TO SUE. I acknowledge that I am signing the agreement freely and voluntarily and have not been forced to volunteer my services or sign this agreement and intend by my signature for this to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Non-Employee/Volunteer Signature: Date:

(FCN-37) (MAY 25)

The following generalized rules and regulations are intended as a guide while utilizing on-site facilities of the Cook County Department of Corrections (CCDOC). You are responsible through your affiliation supervisor to the CCDOC Executive Director or the authorized designee. Initial the below listed rules and regulations indicating you have read and understand them:

INITIAL: No contact or communication outside of the CCDOC including telephone, text, or interaction with individuals in custody [IICs] or their family or friends unless specifically authorized by the Executive Director of the CCDOC. You are prohibited from trading, bartering, lending or otherwise engaging in any personal transactions with any IIC. You may not deposit money into any IIC’s trust account. You will not share or disclose any personal, occupational, or familial information to those in custody.

INITIAL: You are subject to a search upon entrance and at any time while on the premises. All items, packages, purses, and bags must be placed on the x-ray machine for inspection and may be searched. There are no exceptions to the search procedures. Search and/or questioning by CCDOC sworn members may occur at any time. Failure to cooperate may be grounds for revocation of your access to the facility

INITIAL: Attempts to enter a penal institution with contraband will result in prosecution. Contraband includes Illegal items such as unlawful drugs, saturated or unapproved paper, drug paraphernalia, and firearms as well as legally possessed prohibited items such as medication, knives, blades, and ammunition. Items secured as contraband are not returnable after seizure. The contraband list is subject to change. I have received and read the most up-to-date list of prohibited items.

INITIAL: Mobile communication devices (e.g., cell phones, tablets, smart phones, smart watch) and recording devices (e.g., cameras, digital/tape recorders) are not permitted and are considered contraband unless approved. Written authorization, issued by the CCDOC, shall be carried on your person at all times.

INITIAL: You are required to immediately notify your sponsor of any involvement with law enforcement as an arrestee, witness, victim, a party in a civil action or any involvement that may jeopardize volunteer status with the CCDOC.

INITIAL: Termination from your employer or disassociation from your organization is grounds for immediate and automatic revocation of your non-employee identification card. You shall not attempt to use your identification card after being terminated from your employer. Expired IDs or those of terminated volunteers must be returned to CCSO Credentials Unit.

INITIAL: The CCDOC reserves the right to deny and/or revoke access into any of its facilities. Violation of any agreed stipulations may result in revocation of privileges as well as criminal prosecution.

INITIAL: No loitering or deviation from direct routes to and from authorized destinations is permitted. Attempts to access unauthorized areas will result in revocation of access.

INITIAL: Display your non-employee identification card at all times, if applicable. Access is limited to a division or area for which authorization is received and only for the purpose, time, and space authorized.

INITIAL: Discrimination, harassment, and sexual harassment directed towards staff, volunteers/contractors, or individuals in custody are strictly prohibited and are grounds for revocation of access and may result in criminal prosecution.

INITIAL: Wear appropriate attire that meets the safety, image, and functionality for the particular role/position. Inappropriate attire includes but is not limited to, shorts, mini-skirts/dresses, sheer pants/tops, gang affiliated or representation of gang clothing, colors, hats, etc.

You may be denied entry on the basis of improper attire.

INITIAL: You must notify respective sponsor if a friend or family member is in the custody of the CCDOC or of affiliation with known offenders.

INITIAL: Notify the immediate CCDOC supervisor if a friend/family member in the custody of the CCDOC is present during a program or in your designated work area. Under no circumstances are you to deviate from the program as established through your sponsor at the CCDOC without prior approval and proper notice of your sponsor.

INITIAL: Under the provisions of the Prison Rape Elimination Act (PREA) of 2003 (42 USC 147), any instance of sexual contact towards individuals in custody will result in criminal charges.

INITIAL: Follow all rules regarding tool inventory and control, including keeping your tools and an accurate tool inventory sheet with you at all times. Be aware of your surroundings and be vigilant with any and all tools and materials you have with you in a correctional facility.

INITIAL: I understand that membership in a known criminal organization shall prohibit me from access. By initialing here, I affirm that I am not a member of or associated with a gang or other known criminal organization

INITIAL: I understand that visitation of inmates in custody is prohibited, unless approved by the Executive Director or the authorized designee in accordance with current Department policy and procedure.

INITIAL: In the event of a lost or stolen non-employee identification credentials, I must file a police report in the jurisdiction in which the identification was lost. The report, along with a memorandum, shall be forwarded to the sponsor and the Sheriff’s Office along with a certified check or money order payable to the Cook County Sheriff’s Office. The current replacement cost is $30.00.

BY SIGNING BELOW, I CERTIFY I HAVE READ AND UNDERSTAND THE ABOVE LISTED RULES AND REGULATIONS.

Name: Signature: Date:

(FCN-37) (MAY 25)

An applicant’s eligibility will be denied if any of the following criteria appears in their criminal background check:

1. Current felony or misdemeanor case pending in any court,

2. Active warrant(s).

3. An active order of protection in which the applicant is listed as a respondent.

4. Member or associate of a known criminal organization.

5. Falsifying or omitting information on the application, including but not limited to, identity theft, criminal history, and/or failure to report any current or prior contact or relationship with an individual in custody.

6. Currently on probation or parole (individual exceptions may apply).

7. Has been in the custody of the CCDOCC, Illinois Department of Corrections (IDOC) or any other verified correctional facility in the last three years for any reason.

8. Previous denial or revocation of non-employee identification.

9. Violent criminal history, drug charges and/or sex offenses to include registered sex offender (current charge, prior conviction, arrest history), any felonies in the past ten years and/or misdemeanors in the past three years, from the date of the conviction or the last day of sentence, whichever is later.

10. Civil or administrative adjudications resulting from sexual misconduct, including any court ordered protective order.

11. Evidence that the applicant does not meet the conduct and ethics standards established by the Sheriff’s

Office.

12. Evidence that the applicant may pose a safety or security threat to the Sheriff’s Office or to individuals in its custody.

The Cook County Sheriff’s Office may revoke a non-employee’s credentials or authorization at any time for any reason. Reasons for revocation include, but are not limited to:

1. Violating the Code of Conduct Agreement.

2. No longer employed by or a volunteer of the agency requesting access.

3. Found in an unauthorized area.

4. Use of identification for purposes other than intended.

5. Any arrest since issuance.

6. Found to have violated any of the non-employee identification standards.

7. Failure to report for three consecutive months.

(FCN-37) (MAY 25)

APPLICANT INFORMATION

Applicant Name: Date:

Date of Birth: JDE Number (if applicable):

Applicant does not have JDE number:

Department:

CCSPD CSD CCDOC EXECUTIVE OFFICE OTHER: ___________________________________

N/A SPONSOR/ VOLUNTEER’S AGENCY (If applicable) Sponsor/Volunteer Agency Name: Sponsor/Volunteer Agency Supervisor: Work Phone:

DENIAL CRITERIA

IDENTIFICATION SHALL BE DENIED IF THE APPLICANT HAS ANY OF THE FOLLOWING IN THEIR BACKGROUND:

� Current felony or misdemeanor case pending in any court Active warrant(s).

� An active order of protection in which the applicant is listed as a respondent.

� Member or associate of a known criminal organization.

� Falsifying or omitting information on the application, including but not limited to, identity theft, criminal history and/or failure to report any current or prior relationship with an inmate.

� Currently on probation or parole (individual exceptions may apply).

� Has been in the custody of the Cook County Sheriff’s Office, Illinois Department of Corrections (IDOC) or any other verified correctional facility in the last three years for any reason.

� Previous denial or revocation of non-employee identification.

� Violent criminal history, drug charges and/or sex offenses to include registered sex offender (current charge/prior conviction/arrest history), any felonies in the past 10 years and/or any misdemeanors in the past three years, from the date of the conviction or the last day of sentence, whichever is later.

� Civil or administrative adjudications resulting from sexual misconduct or any protective order.

� Evidence that the applicant does not meet the conduct and ethics standards established by the Sheriff’s

Office.

� Evidence that the applicant may pose a safety or security threat to the Sheriff’s Office or to individuals in its custody.

� Other: ______________________________________________________________________________

APPROVAL

Approved Denied HR Analyst: Signature: Date:

Application denial: Signature: Date:

Comments:

HR Supervisor/Designee:

Application status:

Authorized Overruled

(FCN-37) (MAY 25)

CONTRABAND

It is a criminal offense to bring, contraband into a penal institution. Visitors who bring, attempt to bring, or leave an item of contraband in the Cook County Department of Corrections (CCDOC) shall be charged criminally with ''Bringing Contraband into a Penal Institution," 720 IL.CS 5/31 A.1. The CCDOC has determined contraband to be but not limited to, the following items:

1. Unnecessary or unapproved paper.

2. Weapons, explosive devices, ammunition, or any item that could cause great bodily harm (e.g., Tasers, stun guns, firearms, grenades, bombshells).

3. Knives of any kind.

4. Imitation weapons, explosive devices, or any item construed or shaped as a weapon.

5. Toxic, hazardous materials or chemicals of any type (e.g., flammable or combustibles liquids, oil).

6. All tools except those authorized for use by the CCDOC.

7. Insecticide, pesticide, or herbicide.

8. Non-plastic eating utensils.

9. Wire, wire rope, rope, string, or twine.

10. Razors or razor blades.

11. Dental floss.

12. Aerosol cans.

13. Steel, aluminum, aluminum foil, tin, or other metal object.

14. Wax, clay, or any substance that could be used as a "mold".

15. Glass or glass objects (other than prescription lenses).

16. Glue, adhesive or masking tape.

17. Intoxicants or alcoholic beverages, ingredients, formulas, or instructions that are used to make intoxicants or alcohol

(e.g., distilled spirits, beer, wine).

18. Illegal drugs or drug paraphernalia.

19. Hypodermic needles or syringes (unless accompanied by a prescription).

20. Plastic or metal instrument modified for use other than its intended purpose.

21. Maps or travel tickets (e.g., airline, train, bus).

22. Flowers (dried or fresh), weeds or foliage.

23. Nail files or nail clippers.

24. Scissors unless authorized by the CCDOC.

25. Paper clips unless authorized by the CCDOC.

26. Chewing gum.

27. Electronic cigarettes, cigarettes, cigars, or any tobacco product, (e.g., rolling paper, loose tobacco).

28. Incendiary devices (e.g., lighters, matches).

29. Radios or video recording devices.

30. Recording or pre-recorded audio or video magnetic tapes (e.g., CDs, DVDs).

31. Televisions unless authorized by the CCDOC.

32. Pagers unless authorized by the CCDOC.

33. Paint.

34. Gambling devices (e.g., dice, poker chips).

35. Mirrors.

36. Electronic devices, including cellular phones and technical manuals unless authorized by the Executive Director.

37. Computers and equipment unless authorized for use by the Executive Director (e.g., CDs, DVDs, storage drives, flash drives, memory cards, monitors, keyboards, mice, cables, software, manuals).

38. Cameras and equipment unless authorized by the Executive Director (e.g., memory cards, cables, software).

39. Food preparation equipment unless authorized by the Executive Director (e.g., coffee makers, hot plates).

40. Books, magazines, newspapers, or pornographic/nude materials, folders, workbooks, printouts, or other documents, unless authorized by the CCDOC.

41. Wearable electronic devices including smart watches.

PREA Volunteer and Contractor Information Acknowledgement Form

The PRISON RAPE ELIMINATION ACT was signed into law in 2003. The law is to prevent, detect, and respond to sexual abuse and sexual harassment. The Cook County Sheriff’s Office has a zero-tolerance policy for sexual abuse and sexual harassment and such conduct is strictly prohibited. We want to ensure you understand the rules of the facility and how to report a problem, or issue in the unlikely event something happens while you are here. You, as a volunteer or contractor seeking authorization to enter the Cook County Department of Corrections, must adhere to these requirements.

Important Rules To Know:

Sexual activity is strictly prohibited.

• Sexual activity includes any kind of sexual contact, regardless of whether the other party agreed to the contact or not. There is no such thing as consent to sexual activity in a correctional setting.

• This also includes sexual harassment: saying sexual things, saying things about someone’s body, talking about who someone likes to date, sexual orientation or identification, or making offensive gestures or comments.

Employees, contractors, and volunteers are prohibited from having any kind of romantic relationship with an individual in custody. There is no such thing as consent to sexual activity in a correctional setting.

Any contractor, volunteer, or employee who engages in sexual abuse, sexual harassment, or discusses content that is sexually inappropriate in nature shall be prohibited from contact with individuals in custody.

You are prohibited from sharing personal information or details of your life , such as their personal contact information, except if necessary to carry out your professional responsibilities.

You are prohibited from contacting individuals in custody outside of the facility through any means (e.g., in person meetings, texting, phone calls, or on social media), without approval of the Sheriff’s Office.

How We Keep Everyone Safe:

At the Cook County Sheriff’s Office, we do a number of things to keep everyone safe, including:

• Educating individuals in custody about their right to be free from sexual abuse, and sexual harassment, conduct, or inappropriate conversations.

• Conducting background checks of the individuals we hire.

• Training employees on our policies on preventing, detecting, and responding to sexual abuse, and sexual harassment.

• Offering multiple ways individuals in custody and others can report problems at each facility.

• Fully investigating all allegations of sexual abuse and sexual harassment.

• Providing services and support to individuals in custody who report they have been sexually abused or harassed.

• Protecting employees and individuals in custody from retaliation for reporting problems or assisting with an investigation.

• Enforcing our rules and requirements as explained above.

(FCN-37)(MAY 25)

PREA Volunteer and Contractor Information Acknowledgement Form

What to do if you see or suspect sexual abuse, and/or sexual harassment, or if the individual in custody is at substantial risk of imminent sexual abuse or sexual harassment, or if an individual in custody reports a problem to you: Although we do a number of things to keep everyone safe, we want you to know what to do if you see something that looks like a problem or if an individual in custody reports a problem to you.

• If you see or suspect an incident of sexual abuse and/or sexual harassment you must report it immediately by informing a staff member (e.g., officer, sergeant/lieutenant, or your program’s volunteer coordinator).

• If you become aware of anyone violating the rules and requirements explained in this Form, you must report this immediately by informing a staff member.

• If an individual in custody wants to tell you something but asks you not repeat what they are going to tell you, let them know about your limits of confidentiality. This includes whether you have to report certain behaviors by law once you have knowledge or reasonable suspicion that a crime is being or has been committed.

o For example, you might say, “I am glad you told me and I can understand why you would not want me to tell anyone. If it is regarding sexual abuse or harassment, I am required to report it. I respect your decision if you do not want to tell me as a result. But if you tell me, I can work with you to get help.”

• If an individual in custody discloses something that suggests an incident of sexual abuse or harassment has occurred, stay calm, listen to what they are saying, take the report seriously, and convey a message of support (e.g., “I’m glad you were strong enough to come to me”).

• Let the individual in custody know you are going to report the incident to DOC staff and that someone will investigate and make sure they are safe. Inform them you will not share their report beyond those who need to know.

Questions: If you have questions pertaining to your PREA responsibilities or other facility rules, or your responsibilities while you are here, you may contact us at ccso.prea@ccsheriff.org.

Acknowledgement: By signing this form, you acknowledge that you have received, read, and understand your responsibilities regarding the Cook County Sheriff’s Office PREA related policy to prevent, detect, and respond to sexual abuse and sexual harassment in confinement settings.

Signature: ____________________________________________ Date: ________________

Printed Name: ___________________________________________________

(FCN-37)(MAY 25)

mailto:ccso.prea@ccsheriff.org