Attachment I - AR 1150-14 Background Investigations.pdf

I. POLICY

It is the policy of the Department of Corrections (DOC) to conduct thorough background investigations on all applicants, to include contract workers, sub-contractors, temporary state employees, student interns, and volunteers [5-ACI-1C-14] [2-CO-

1C-18] [4-APPFS-3A-02] [1-CTA-1C-06]. These investigations are conducted by Office of Inspector General (OIG), employees and contract workers in cooperation with the Office of Human Resources, Employment Services Unit, and in compliance with state statute. Successful completion of a background investigation is a prerequisite to eligibility for employment or other statuses as defined below.

II. PURPOSE

The purpose of this administrative regulation (AR) is to define the responsibilities of the Office of the Inspector General, Background Investigation Unit (BIU) and to delineate the background investigation process.

III. DEFINITIONS

A. Applicant: Any individual who applies for full-time, part-time, temporary, contract employment or student internship with the DOC.

B. Background Investigation: A thorough and systematic inquiry into the personal history of an individual to determine eligibility for employment with the Department of Corrections. Investigations may include but are not limited to; criminal history checks, employment checks, financial history checks, interviews, credential checks, field investigations, polygraphs, and/or psychological exams. May consist of all or some of the following phases:

1. Phase I – criminal history check, driving history, employment check, credential checks, and DOC database check.

2. Phase II – A structured integrity interview.

3. Phase III – Field investigations, polygraphs and psychological exam.

C. Backgrounds Standards: An objective set of confidential standards which identify disqualifiers utilized to determine the eligibility or ineligibility of an applicant. Such standards will be static during the year but reviewed on an annual basis with this administrative regulation to determine the need to add or delete standards based upon changing law or the changing mission of the Department of Corrections. All standards will be specifically formulated to ensure compliance with ADA and

EEO laws and guidelines, personnel rules, and applicable statutes. The standards will reflect the Department’s mission and

ADMINISTRATIVE REGULATION

COLORADO DEPARTMENT OF CORRECTIONS

REGULATION NUMBER

1150-14

PAGE NUMBER

CHAPTER: Investigations

SUBJECT: Background Investigations

RELATED STANDARDS: ACA Standards: 2-CO-1C-10, 2-

CO-1C-18, 4-APPFS-3A-02, 5-

ACI-1C-14, 1-CTA-1C-06

EFFECTIVE DATE: September 1, 2022

SUPERSESSION: 06/01/21

Dean Williams

Executive Director

OPR: OIG REVIEW MONTH: AUGUST

CHAPTER SUBJECT AR # Page 2

Investigations Background Investigations 1150-14

EFFECTIVE

09/01/22 the specific needs and requirements necessary for persons who work in a corrections (law enforcement) environment. All standards will be maintained as criminal justice records and pursuant to statute, will not be disclosed except to the Executive

Director, Inspector General, OIG DOC employees and contract workers with a need to know, and the Chief Human

Resource Officer. All changes to standards will be ratified yearly by the executive director.

D. Classification transfer: An appointment of a qualified and current employee to a different class with the same pay range maximum.

E. Promotion: An appointment from a promotional or open competitive list changing a DOC employee from one class of work to a different class at a higher pay grade. A promotion to a position at another facility/office is not a transfer.

F. Temporary State Employee: A qualified person who is appointed to a non-permanent position. Temporary state employees are employed at will and do not have the rights and benefits provided to permanent DOC employees, except those mandated by law and pay grade minimum.

G. Voluntary Demotion: An appointment which is a voluntary change to a class with a lower pay range maximum.

IV. PROCEDURES

A. Background Investigations:

1. All applicants, intra-agency transfers, reinstatements, interns, contract workers, or chaplains will be made aware by the appointing authority that appointments and/or continued employment are contingent upon completion of a successful background investigation. Refusal to participate in any portion of the background process will disqualify a person from employment with the DOC. Any false, incomplete, inaccurate, or omission of information requested during the background investigation may be grounds for disqualification for employment or following an appointment, termination from employment.

a. Those applying for classified, non-classified, or management positions will complete the required background questionnaires as a part of the required online application process.

1. Before hiring new employees who may have contact with offenders, DOC will: (115.17(c)):

a) Perform a criminal background records check; [2-CO-1C-18] [4-APPFS-3A-02][ 5-ACI-1C-14][1-CTA-

1C-06] and

b) Consistent with Federal, State, and local law, BIU will make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or sexual assault or any resignation during a pending investigation of an allegation of sexual abuse or sexual assault.

b. Those applying for interns (requesting more than 3 months’ access), contract workers, or anyone with criminal justice information (CJI) access and/or unescorted offender contact will complete AR Form 1150-14A, Background Questionnaire.

1) Upon successful completion of the background investigations process, BIU will make necessary notifications via e-mail regarding temporary employees, contract workers, etc., so that required on-line training and orientation can be scheduled by the appropriate supervisor.

2) BIU will then enter the information in DCIS as necessary.

3) A preliminary background check every 12 months may be required for continued eligibility.

c. Those applying for volunteers or chaplains, refer to AR 900-01 Volunteer Programs.

CHAPTER SUBJECT AR # Page 3

d. All others, (including interns requesting less than 3 months’ access), refer to AR 300-27 Access and Control.

2. A preliminary background check will be conducted on an applicant if that applicant has not previously been selected for employment with the DOC, but has previously passed a background investigation in less than a one year time period.

The preliminary check includes, but is not limited to, an NCIC/CCIC check and court records review. A Phase II integrity interview may be required by BIU.

3. DOC will conduct criminal background records checks at least every five years for current employees and contractors who may have contact with offenders. (115.17(e))

4. All promotional candidates will be made aware by the appointing authority that promotions are contingent upon successful completion of a background investigation as outlined by Federal mandate. (115.17).

5. The Office of Human Resources will provide the BIU with the promotion checklist and a copy of the promotional candidate’s employer master query sheet.

B. Background Investigation Process:

1. Phase I: Phase I background investigations will routinely consist of employment checks, NCIC/CCIC criminal history, driving record checks, court checks, and employment verification checks. Financial history checks and credential checks may be conducted during this phase or in a later phase, as the need arises. Applicants may be deemed ineligible at this level if they fail to meet DOC standards. Applicants who meet the standards at this stage may be required to participate in Phase II.

2. Phase II: Phase II consists of an integrity interview with an interview technician or an investigator.

3. Phase III: Phase III consists of a polygraph and/or psychological examination to verify the applicant’s history, statements, or written responses.

a. Community parole officer and criminal investigator applicants may be required to submit to a polygraph and/or psychological assessment and/or a field investigation to determine suitability for employment. These additional requirements are necessary for these classifications due to their heightened contact with potentially armed offenders or suspects and their requirement to carry and potentially use lethal force in the community setting. These additional requirements are necessary to satisfy Colorado Peace Officer Standards and Training standards criteria.

b. Positions other than community parole officers or criminal investigators may be required to complete a polygraph and/or psychological examination based on the recommendation of the BIU. The request for a polygraph must be made to the inspector general or designee who will decide whether the examination will be required.

4. Upon completion of the required phase(s) of the process, the background technician will make a recommendation regarding eligibility based upon the confidential standards criteria. If the applicant is determined ineligible, the BIU manager will ensure proper application of the department standards and an ineligibility letter will be sent to the applicant. The eligibility status of candidates will be made available to the Employment Services Unit.

C. The collection of personal information during the background process is used to determine the eligibility of applicants for employment and any use of the information outside the scope of its intended purpose is unauthorized. The DOC has a duty to protect the rights of applicants who disclose personal information during the background investigation process.

Backgrounds are conducted for business purposes and the information contained in background files is considered criminal justice records, which is confidential. The information contained in background files may only be used for employment purposes or conducting Professional Standards Investigations as needed. The background files of successful applicants are available to those individuals involved in the hiring process who would need the information to complete their job duties and the Chief Human Resources Officer. The files of unsuccessful applicants are confidential and cannot be divulged to anyone outside the Office of the Inspector General without the written consent of the unsuccessful applicant and the prior permission of the Inspector General or designee. Any violation of this policy may result in corrective and/or disciplinary action.

CHAPTER SUBJECT AR # Page 4

D. Any information discovered during the background investigation that may be construed to have potential terrorism connections must be forwarded to the local Joint Terrorism Task Force (JTTF) or another like agency. [5-ACI-1C-14][1-

CTA-1C-06]

E. For information regarding employment of family members, former offenders (less than 3 years), and ex-offenders (3 years or more) within the DOC, refer to AR 1450-16, Employment of Relatives and Former and Ex-Offenders.

F. Prison Rape Elimination Act Requirements:

1. DOC will not hire or promote anyone who may have contact with offenders, and will not enlist the services of any contractor who may have contact with offenders, who (115.17(a)).

a. Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997);

b. 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

c. Has been civilly or administratively adjudicated to have engaged in the activity described in paragraph (a) of this section.

2. DOC will consider any incidents of sexual harassment in determining whether to hire or promote anyone, or to enlist the services of any contractor, who may have contact with offenders (115.17(b)).

3. DOC will ask all applicants and employees who may have contact with offenders directly about previous misconduct, described in IV E. in this policy, in written applications or interviews for hiring or promotions and in any interviews or written self-evaluations conducted as part of reviews of current employees. DOC will also impose upon employees a continuing affirmative duty to disclose any such misconduct (115.17(f)).

4. Material omissions regarding such misconduct, or the provision of materially false information, will be grounds for termination (115.17(g)).

5. Unless prohibited by law, DOC will provide information on substantiated allegations of sexual abuse, sexual assault or sexual harassment involving a former employee upon receiving a request from an institutional employer for whom such employee has applied to work (115.17(h)).

G. Classification Transfers and Voluntary Demotions:

1. A preliminary background check will be conducted on those applying for transfer or demotion from a non-correctional series to a correctional series, community parole officer, or criminal investigator positions to ensure no driver’s license or firearms restrictions exist.

V. RESPONSIBILITY

A. The BIU manager will be responsible for the management and evaluation of the BIU and is the custodian of all background investigation files. The BIU manager maintains records and statistics and produces a weekly activity report.

B. The Inspector General is responsible to review this information annually and update as necessary.

VI. AUTHORITY

CHAPTER SUBJECT AR # Page 5

A. 17-1-103.8. Duties of executive director - inspector general - investigators - duties.

B. Colorado State Personnel Board Rules.

C. 17-1-109.5 Correctional facility employees - rules

VII. HISTORY

June 1, 2021

May 1, 2018

March 15, 2017

March 15, 2014

April 1, 2013

May 1, 2012

February 1, 2011

January 1, 2010

January 1, 2009

January 1, 2008

January 1, 2007 (supersedes AR 1450-29)

ATTACHMENTS:

A. AR Form 1150-14A Background Questionnaire

B. AR Form 100-01A, Administrative Regulation Implementation/Adjustment

Colorado Department of Corrections

Background Questionnaire

This information is needed for CDOC to conduct a criminal history check to determine whether access to CDOC units and departments should be approved. All questions MUST be answered in full or the application will be considered incomplete and will result in disqualification.

Contract Employee Full Time Employee Temp Employee / Intern Position Title:

Contracting Agency:

1. Name:

Last First Middle

2. SSN (xxx-xx-xxxx): Date of Birth (mm/dd/yyyy):

3. Other Names Used (Maiden, Alias, etc.)

4. Mailing Address: _ Street City State Zip

5. List all States you have lived in:

Place of Birth:

City State or Country (if outside the US)

6. Driver’s License Number: State:

7. Phone No.: Cellular No:

8. Sex: Male Female Other

9. E-mail address:

10. Ethnic Origin: White Black Hispanic Asian/Pacific Islander American Indian/Alaskan Other

11. Have you been previously employed by CDOC or worked in a CDOC facility under contract? Yes No If yes, give facility, position(s) held and dates:

12a. Are you or any immediate member of your family (to include, but limited to parent, brother, sister, spouse, child) related to a CDOC offender (incarcerated or on parole)? Unknown Yes No 12b. If yes provide the name of the offender(s)

13a. Are you now or have you ever been involved in a spousal relationship with a CDOC offender (incarcerated or parole)? This includes marriage, common-law marriage, lived together, or had a child together. Yes No 13b. If yes provide the name of the offender(s)

Form A

AR Form 1150-14A (09/01/22)

AR Form 1150-14A (09/01/2022)

13c. Do you have currently have or have you ever had a business relationship or gang association with a current CDOC offender (incarcerated or on parole)? Yes No If yes provide the name of the offender(s)

13d. Are you currently on a CDOC offender’s visitation list? Yes No

13e. In the last year, have you corresponded via telephone or mail with a current CDOC offender? Yes No

NOTE:

• If you have a personal relationship with an offender, who is not a family member, be sure to read the “Offender Relationships” paragraph on page 5 of this questionnaire.

IMPORTANT

A criminal record may not necessarily make you ineligible for employment. However, any omission or falsification of information on the questionnaire will result in disqualification for contract employment access to CDOC facilities, regardless of qualifications. List all charges, regardless of when they occurred, to include any court appearances, felonies, misdemeanors (including DUI), juvenile offenses including any charges that were dismissed, deferred dismissed and sealed records.

14. Do you have any current criminal charges pending? Yes No

If yes, please explain

15. Are you on parole, probation, deferred sentence or under a pre-trial diversion agreement? Yes No

If yes please explain

16. Have you ever been investigated, arrested or convicted of any criminal offense? Yes No If yes provide list below:

Date

Felony or Misdemeanor

Offense

City/State

Disposition

Attach an additional page if necessary.

17. Have you ever been ticketed, arrested or convicted of any traffic offense? Yes No If yes provide list below:

Date

Violation/Offense

City/State

Disposition

Attach an additional page if necessary. List all charges, regardless of when they occurred, to include any court appearances

DOCUMENT REQUIREMENTS: You are required to provide with this questionnaire a disposition for each criminal charge you reported in Question 15, 16, and 17 above. A disposition is a statement of the charge, date, and the results of the case. If the charge was dismissed, the disposition will state the reason for dismissal. Dispositions can normally be obtained from the clerk of the court having jurisdiction over the case.

18. Are you now are have you ever been a member or associated with a street gang? Yes No

If you answered yes to either of these questions, provide the following information:

a. Name of the organization and dates of membership:

b. Position or positions you held in the organization:

c. Arrests and/or convictions resulting from your activities as a member:

19. Do you have any tattoos or markings on your body signifying membership or affiliation with a street gang or associated with organizations promoting racial, ethnic, or gender superiority or separation, independence from governmental laws and regulations, or overthrow of the United States Government? Yes No

If yes, provide a description and location of those tattoos or markings:

20. Have you ever used or experimented with any illegal drugs, to include marijuana? Yes No

If yes please provide a list of all drugs used, length of use, frequency of use and date of last use (Attach an additional page if necessary).

21. Have you ever participated in the manufacture, cultivation, or sale of any controlled substances? Attach an additional page if necessary. Yes No

If yes, please explain

22. To ensure the CDOC upholds its commitment to provide a safe and secure work environment, the use of any drug classified under the Federal Controlled Substances Act, including medical or recreational marijuana is prohibited. We are committed to maintaining a drug and alcohol free work environment, and our employees are expected to comply with all state and federal laws. A pre-employment drug test will be administered at any part of the selection process, and applicants who test positive for any controlled substances will be disqualified from consideration. I acknowledge that all prospective Department of Corrections employees/contractors will be required to submit to a urinalysis test for drug use (including marijuana). I acknowledge that, if hired, I will submit to drug testing. I acknowledge that if I refuse testing or test positive for a drug, I may be subject to corrective and/or disciplinary action, up to and including termination.

I so acknowledge and understand the above statements. Yes No

Prison Rape Elimination Act Questions

23. PRISON RAPE ELIMINATION ACT 1 - The following 7 questions relate to the Prison Rape Elimination Act of 2003: I have not engaged in sexual abuse in a prison/jail/lockup/community confinement facility/ juvenile detention facility or other institution (e.g., facility for mentally ill, disabled, chronically ill, or handicapped; residential care or treatment facility for juveniles; facility that provides skilled nursing, intermediate or long-term care, or custodial or residential care). True False

24. PRISON RAPE ELIMINATION ACT 2 - I have never been convicted of engaging or attempting to engage in sexual activity by force, overt or implied threats of force, or coercion , or if the victim did not consent or was unable to consent or refuse. True False

25. PRISON RAPE ELIMINATION ACT 3 - I have not been convicted of or otherwise found (civilly, administratively, or through any formal fact-finding process ) to have engaged or attempted to engage in sexual activity in any setting overt or implied threats of force, coercion, or if the victim did not consent or was unable to consent or refused. True False

26. PRISON RAPE ELIMINATION ACT 4 - I have not been investigated for, disciplined for, convicted of, civilly or administratively adjudicated of having engaged in sexual harassment? True False

27. PRISON RAPE ELIMINATION ACT 5 - I have not engaged in any incident of sexual abuse, sexual assault or sexual harassment not addressed above. True False

28. PRISON RAPE ELIMINATION ACT 6 – If your answer is “False” to any of the questions relating to the Prison

Rape Elimination Act, please provide a written explanation: No False Answers

If any false please explain:

29. Prison Rape Elimination Act 7 - Acknowledgement: All answers and statements are true and complete to the best of my knowledge. I understand that untruthful answers or deliberate omissions may be cause for termination or not being hired. True False

FALSIFICATION POLICY

It is important that contract employee applicants provide accurate information in this questionnaire. Failure to list any criminal conviction or other important information, such as prior employment with CDOC or offender relationships, is considered falsification of the questionnaire and results in disqualification for contract employment access to CDOC facilities for one year.

CDOC is a criminal justice agency, therefore it is very important that we know if an applicant has a criminal record. In most cases, a criminal record does not disqualify you for access to CDOC facilities. However, falsification of the questionnaire always disqualifies you, regardless of how well qualified you are otherwise.

What convictions will be listed? All convictions handled in adult court will be listed, no matter when or where they occurred. In Colorado, if you are 18 years old or older, the case is always handled in adult court. If you are under 18, it still may be handled in adult court. As an exception, you are not required to list convictions for minor traffic violations.

Examples of minor traffic violations are speeding, running stop signs, and no seat belts. Examples of crimes which are not minor traffic violations and will be listed are DWI, DUI, Hit and Run, Assault with a Motor Vehicle, Reckless

Driving, Open Container, and Driving While License is Suspended. Convictions that have been expunged under state or federal law do not have to be listed. Expunged means a judge signed an order directing all agencies with a record of the arrest and conviction destroy those records (this is not the same as a deferred adjudication, explained below).

What is a conviction? For CDOC purposes, a conviction is a judgment or a verdict, a plea of guilty or nolo contendere, and/or a judicial finding of guilt substantiated by the evidence, which results in the payment of fines, forfeiture of collateral or bond, restitution, deferred adjudication, probation, community supervision, confinement, suspended sentence, or any other penalty imposed by a court of law or agreed upon by the accused. This includes instances where a pardon or a reprieve has been granted for any reason other than proof of innocence. If you have a case handled by deferred adjudication, it MUST be listed in this questionnaire, regardless of whether you think it is still on your record. On the other hand, a pre-trial diversion agreement is not considered a conviction for the purpose of employment with CDOC but should still be included on your application.

Military Convictions. Convictions by court martial for criminal offenses will also be listed.

Failure to Appear. If you were convicted of a routine traffic violation or other offense and did not pay the ticket on time or failed to appear to court, you may have been charged with and convicted of Failure to Appear. Failure to Appear is a separate crime and will be listed.

Questions. If you have any questions concerning what will be listed in this questionnaire, it is recommended you contact the Background Investigations Unit at (719) 226-4340 before you submit this questionnaire.

Offender Relationships

CDOC employees and contract employees with access to CDOC facilities are prohibited from maintaining or developing a personal relationship with an offender who is not related to the employee. Prohibited relationships include those involving cohabitation, sexual misconduct, or actions that jeopardize or have the potential to jeopardize the security of the CDOC. This means employees and contract employees may not have personal contact or relationships with offenders currently incarcerated or on parole outside of their official duties if this contact or relationship would jeopardize or has the potential to jeopardize the security of the CDOC. Prohibited contact includes living together, writing letters or notes, telephone contact, visitation, and depositing funds into an offender’s J-Pay account. If an employee or contract employee was once married to an offender or had a child together with an offender, employee contact with the offender may be limited to that which is ordered by the Court.

As a condition of contract employment with CDOC, contract employees with prohibited relationships will sever those relationships. Sever means to cease any and all cohabitation, intimate encounters, verbal or written communications, visitation, or other prohibited contact. Continuation of a prohibited relationship after contract employment with CDOC may result in denial of access to CDOC facilities, if the CDOC determines the relationship jeopardizes or has the potential to jeopardize the security of the CDOC.

Certification I certify that I have read and understand the above explanation of the CDOC Policy on Falsification and Offender Relationships. I further certify that my answers on this questionnaire are true, complete and correct to the best of my knowledge and I have not evaded or omitted any part thereof to reflect an untruth. I understand falsification constitutes grounds for refusing or terminating access to CDOC units and departments.

Signature: Date:

ADDITIONAL OFFENDER INFORMATION

Applicant’s Name: Social Security Number:

As a criminal justice agency, we need additional information from you concerning any relationship with a current or previous offender. This information may affect your eligibility for employment or the unit or department to which you are assigned. Please provide the following information regarding the relationship. Complete a separate form for each relationship.

Check this box if you do not have a relationship with a current or previous offender.

OFFENDER INFORMATION

Offender Information:

Name: CDOC Number: Date of Birth:

Currently Incarcerated in CDOC Unit:

Currently on Parole: City of residence:

In County Jail waiting for transfer to CDOC:

Former CDOC offender (no longer on parole)____________________________

DESCRIPTION OF RELATIONSHIP

Type of Relationship: (Check the appropriate box below and answer the questions under that box:

Relative (other than spousal relationship): How is this offender related to you?

Spousal Relationship (Select the box below that describes the spousal relationship)

Legally married Common-Law marriage Legally married by Proxy Lived together Had child together

Date of marriage, if married: Date of divorce, if divorced:

Dates that you lived together:

Current Business Partnership or Gang Association:

Other: Please describe:

CONTACT INFORMATION

1 Are you on this offender’s visitation list? Yes No Do not know Not applicable

2. Have you visited this offender? Yes No If yes, how often? Last visit?

3. Do you visit or correspond with or have any other contact with this offender? Yes No If yes, please explain:

4. When did you first meet this offender? Month Day Year

5. How did you first meet this offender?

Applicant’s Signature (Required) Date

EMPLOYMENT HISTORY

This information will be the official record of your employment history and must accurately reflect all significant duties performed.

Summaries of experience should clearly describe your qualifications.

1. Include ALL employers in the last ten (10) years. Begin with your current or last position and work back to your first. Employment history should include each position held, even those with the same employer.

2. EMPLOYER ADDRESSES MUST BE COMPLETE MAILING ADDRESSES, INCLUDING ZIP CODE.

3. Answer all questions and completely summarize your experience

If you need additional space to adequately describe your employment history, you may use this employment history sheet or attach a typed employment history providing the same information in the same format as this application form.

Name:

Last First Middle

Employer: Mailing

Address: City &

State/ZIP:

Employer’s Telephone No.: ( )

Immediate Supervisor Name:

Title:

Full-Time

Part-Time

Summer

Temp/Project

Supervisor’s Telephone No.:

Give average # of hours worked per week if part-time:

Starting Date Leaving Date Current/

Final Salary

Technical Mo. Day Yr. Mo. Day Yr. Non-Managerial If supervisory, number of employees you supervised: Supervisory/Managerial

Summary of experience including special training/skills/qualifications you have used in the performance of this job:

Specific reason for leaving – Termination Yes No :

Employer: Mailing

Address: City &

State/ZIP:

Employer’s Telephone No.: ( )

Immediate Supervisor Name:

Title:

Full-Time

Part-Time

Summer

Temp/Project

Supervisor’s Telephone No.:

Give average # of hours worked per week if part-time:

Starting Date Leaving Date Current/

Final Salary

Technical Mo. Day Yr. Mo. Day Yr. Non-Managerial If supervisory, number of employees you supervised: Supervisory/Managerial

Summary of experience including special training/skills/qualifications you have used in the performance of this job:

Specific reason for leaving – Termination Yes No

ADMINISTRATIVE REGULATION

IMPLEMENTATION/ADJUSTMENTS

AR Form 100-01A (04/15/08)

CHAPTER SUBJECT AR # EFFECTIVE

Investigations Background Investigations 1150-14 09/01/22

(FACILITY/WORK UNIT NAME) ______________________________________________________________________

WILL ACCEPT AND IMPLEMENT THE PROVISIONS OF THE ABOVE ADMINISTRATIVE REGULATION:

[ ] AS WRITTEN [ ] NOT APPLICABLE [ ] WITH THE FOLLOWING PROCEDURES TO ACCOMPLISH THE INTENT

OF THE AR

(SIGNED) (DATE) ___________________________

Administrative Head

Attachment B