Attachment 1- LEIN Packet-CFA.pdf

Included in the LEIN packet are

(1) LEIN Authorization Cover Sheet

(2) LEIN Request (CAJ-1037)

(3) Offender Contact Disclosure for Contractors

LEIN Authorization Request Cover Sheet

Date of LEIN request:

Contractor/Vendor:

Subcontractor Name (If applicable):

Employee personal e-mail address:

Employee personal telephone Number:

Position:

Are you related to or acquainted with any offender(s) under MDOC supervision including prisoners, parolees or probationers? Yes No

If you answered yes, you MUST complete the Offender Contact Disclosure for Contractors included with the LEIN packet.

Law Enforcement Information Network (LEIN) investigations must be conducted prior to hire and annually for any person working under an MDOC contract who provides direct services, enters an MDOC secure perimeter, handles or may have access to offender records, offender contact or provides supervisory services to staff performing any of the previously identified functions. The LEIN request (CAJ-1037) form must be completed and typed by the contracted agency, signed by the candidate/employee, and then sent to the Michigan Department of Corrections (MDOC) via the email address MDOC-PMCD-CFA- LEINS@michigan.gov

When submitting your LEIN request via e-mail please make sure to identify the following information in the subject line: Contracted Agency, Position type, whether the request is for a New Position or Annual LEIN and provide the candidate/employee’s name.

Example: Contracted Agency Name/ Clinical Supervisor/ New Position/ Candidate’s Name.

Prior to submitting your LEIN request, please ensure the candidate has been vetted and meets the contractual requirements and that the LEIN Information Form (CAJ-1037) is completed as required.

Please include a copy of the candidate/employee’s State Identification.

The LEIN Operator will respond to the LEIN request within ten business days to advise whether the LEIN is approved, denied, and/or pending MDOC Leadership review.

* LEIN requests not submitted as outlined above will not be processed. *

Rev 10.20.21

MICHIGAN DEPARTMENT OF CORRECTIONS

LEIN REQUEST

CAJ-1037

REV. 06/19.

Please provide the information requested below. This information will be used to complete a criminal history check in the Michigan Law Enforcement Information Network (LEIN).

Your Driver’s License Number or State Identification Card Number, date-of-birth, race and sex is needed to complete this LEIN.

Employment/Human Resources HR Personnel/Requesting

Contractor

Visitor

Contractor Agency Agency Representing

Volunteer

Other

Agency Representing Agency Representing

Are you entering the secure perimeter of an Michigan Department of Corrections (MDOC) facility? Yes No

Please print information below:

Last Name: First Name: Middle Name:

Address:

City: State: Zip Code:

Date of Birth: Sex: Race:

Please provide the number of one of the following types of identification:

Driver’s License #: State issued by:

State ID #: State issued by:

I authorize the MDOC to conduct a criminal history check, so that I may be approved to enter the secure perimeter of an MDOC Facility to perform work, visit, meet with or work with MDOC offenders, or for other purposes approved by the MDOC for Employment/Human Resources purposes.

Signature:

Date:

LEIN Completed By: Name: Date:

LEIN Cleared: Yes No (Does not apply to Human Resources)

MDOC Employment/HR purposes: Indicate the # of convictions

Comment (Optional):

Offender Contact Disclosure for Contractors MDOC contracts require all contractor or subcontractor personnel disclose if they are related to (or acquainted with) offenders. Offenders are defined as active MDOC prisoners, parolees, or probationers.

Please complete one form for each offender you are related to (or acquainted with).

Contracted Employee Name:

(Print or Type)

What Contractor do you work for?

(Print or Type)

What is your position/title?

(Print or Type)

When did you begin working for this Contractor?

(Print or Type)

Please list your email address(es) (Print or Type)

Please list your phone number(s) (Print or Type)

Offender’s Name:

Offender’s Number:

What is your relationship to the offender?

Please answer “Yes” or “No” below to disclose the nature of your relationship. YES NO Do you have contact with this offender?

Do you have in-person visits with this offender?

Do you have video visits with this offender?

Do you speak with this offender on the telephone?

Do you correspond with this offender via mail?

Do you correspond with this offender via email?

Do you send this offender packages via Securepak?

Do you deposit money into this offender’s account?

Comment Section (please include any comments you want to share):

Contracted Employee Signature Date

Page 2 is reserved for internal MDOC use only.

Please review this request approving or denying the contracted employee to provide services under this contract. The contracted employee has acknowledged that they are related to or acquainted with an MDOC offender(s); your approval is requested for the contracted employee to provide services under the contract.

Approved

Denied

If denied, please provide a basis for denial:

Director, Deputy Director, or Designee (Signature) Date

Rev 10.1.21