Appendix_K_DOC_Facility_Site_Visit_Application.doc

APPENDIX K:

Application for Access to Minnesota Correctional Facilities/Sites for Non-DOC Personnel Renewal

DOC Staff Contact: ________________________________________ Activity:____________________________

NAME OF GROUP OR ORGANIZATION:_______________________________________________________ Full name:____________________________________________________________________________________

Please print

(LAST),

(FIRST)

(MIDDLE)

(MAIDEN)

Date of birth: __ __/__ __/__ __ __ __ Male:_____ Female:_____ Race/Ethnicity:________________

Month / Day / Year

Home Phone: ____________________ Cell Phone:______________________ Work Phone:___________________

E-mail Address (Optional): _______________________________________________________________________

Address: _____________________________________________________________________________________

IMPORTANT: Include permanent address AND mailing address, if different. Permanent address needs to match address on valid ID.

City/State:________________________________________

Zip Code:___________________________ Circle type of ID used (Proper photo ID is required)

1. Valid Driver’s License from State of Residence

4. Valid Military ID (Active Duty only)

2. Valid ID Card from State of Residence

5. Valid Passport (If resident of foreign country)

3. Valid Tribal ID (As detailed in M.S. §171.072(b)(c)) 6. Other Valid photo ID Write the ID number here:_____________________________________

State:______________ Have you ever worked for the State of Minnesota?

No___ Yes___

If yes, when and in what capacity? _______________________________________________________________

Have you EVER been convicted of a felony?

Have you EVER served time in a MN DOC facility?

Do you have ANY charges pending against you?

Are you, or have you been, on probation, parole, or supervision in the last year?

No___ Yes___

Agent Name:________________________________ Agent Phone: (____)_________________________ Agent Signature:______________________________________________________________________________ Are you communicating with an offender at ANY facility?

Are you related to or acquainted with an offender at ANY facility?

Are you currently volunteering at another facility? (If yes, list facility below)

Are you applying for admittance to more than one facility? (If yes, check all facilities below)

Are you, or have you been, on an offender’s visiting list at ANY facility?

(If yes, please provide offender name, OID number, and date of last visit below.)

Offender Name:_____________________________ OID:_____________________ Date of last visit:___________ Reason for offender association: ___________________________________________________________________ Emergency Contact By signing below, I attest that my justification to attend the site visit is for the purpose of participating in the Incarcerated Person Communication Services solicitation.

Name: ________________________________________________________ Phone: ______________________

Please place an X next to all facilities you are requesting to enter, and/or provide professional services at:

___MCF-Faribault

1101 Linden Lane Faribault, MN 55021 ___MCF-Lino Lakes

7525 4th Ave.

Lino Lakes, MN

55014 ___MCF-Moose Lake

1000 Lake Shore Dr.

Moose Lake, MN

55767 ___MCF-Oak Park Heights

5329 Osgood Ave. N.

Stillwater, MN

55082 ___MCF-Red Wing

1079 Highway 292

Red Wing, MN

55066 ___MCF-Rush City

7600-525th St.

Rush City, MN

55069

___MCF-Shakopee

1010 W. 6th Ave.

Shakopee, MN

55379 ___MCF-St. Cloud

2305 Minnesota Blvd. S.E St. Cloud, MN 56304 ___MCF-Stillwater

970 Pickett St. N.

Bayport, MN

55003 ___MCF-Willow River (CIP)

86032 County Hwy. 61

Willow River, MN

55795 ___MCF-Togo

62741 County Rd. 551 Togo, MN

55723 ___Central Office

1450 Energy Park Dr.

#200

St. Paul, MN

55108

Guidelines

1. All persons must be at least 18 years old to enter adult facilities, and at least 21 years old to enter juvenile facilities.

2. All person(s) must submit a completed application, pass a background check, and receive orientation before beginning their duties. This process is repeated on an annual basis.

3. All persons must present valid photo identification for each admission to the correctional facility.

4. All person(s) are subject to metal detection to enter a facility. If you have an existing medical reason (with documentation), such as a metal implant, you will be hand-held detected, if you have a Pace Maker or Defibrillator (with documentation) you will be pat searched. If you do not have medical documentation you may not enter the facility.

5. No person can be on an offender’s visiting list in the MN Dept. of Corrections unless approved by the warden or designee.

6. A successful application does not guarantee acceptance into a facility.

Prison Rape Elimination Act

A prior criminal conviction will not automatically remove you from consideration to enter a Facility, However, the MN Dept. of Corrections shall not enlist the services of any contractor who may have contact with inmates who has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution; has 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; or has been civilly or administratively adjudicated to have engaged in the activities described previously. (Per PREA 28 C.F.R Part 115.17)

Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution; or 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; or has been civilly or administratively adjudicated to have engaged in the activities described previously?

Yes _______ No _______ Initial _______

Tennessen Notice/Permission to Do Criminal History Check

During the process of applying to a facility, you will be asked to provide information that may be private under the Minnesota Government Data Practices law. This data will be used to verify and evaluate the information you provide and to ensure the security of the facility. Individuals who have access to this information include any staff who are assisting with applicant background investigations and Office of Special investigations staff. Providing this information is voluntary; however, refusal to provide, failure to disclose, or attempts to withhold this information will be grounds to disqualify you from further consideration for providing services.

An applicant being considered for participation in the Minnesota Department of Corrections will have their criminal history checked. We need your consent and certain private information in order to do a criminal history check.

By providing this information I hereby authorize and grant my informed consent to the Minnesota Bureau of Criminal Apprehension to release to the Minnesota Department of Corrections any information contained about me in the Minnesota Predatory Offender Registry, including, but not limited to, information related to offenses which may have occurred when I was a juvenile, and information in other BCA systems.

I hereby release the Minnesota Bureau of Criminal Apprehension and the Minnesota Department of Corrections from any and all actions and causes of action, of any kind and nature whatsoever, past, present, and future, arising out of the release of information obtained with this consent. This authorization shall be valid for a period of twelve (12) months from the date of signature.

Signature:____________________________________________

Date: _______________

Return completed application to: Janeen Oien at Janeen.Oien@state.mn.us Official Use Only

BCA/QWI check:_____/_____ Clear Visiting check: _____/_____ Clear ID check: _____/_____ Clear

Staff initials / Date

Checks completed by: _________________________________ _________________________________ ____________

Print name

Signature

Date

Reviewing Authority/Designee:

Approved:_________ Denied:_________

Print name:_______________________________ Signature:_________________________________ Date:__________

Mantoux test required? Yes___ No___ Orientation completion date:_________ Staff Signature:_______________________

300.020A (12/2020)