Background Clearance Form~1.pdf
PDF 153 KB Posted
- Attached to
- DRM 2026_37 New Dialysis Room MCI Shirley
- Solicitation number
- BD-27-1025-DOCFS-1000E-132222
- Issued by
- Worcester County, Massachusetts
About this file
This is a Background Clearance Form issued by the Commonwealth of Massachusetts Executive Office of Public Safety & Security, Department of Correction, located at 50 Maple Street, Suite 3, Milford, MA 01757. The form is designed to collect personal information and authorize background investigations for new employees, contract employees, or other individuals requiring clearance to work with or access the Department of Correction. The form requires submission of personal data including full name, residential address, driver's license information, date and place of birth, and family background details. According to the related contract opportunity DRM 2026_37 for a New Dialysis Room at MCI Shirley, pre-site visit documents including the Background Clearance Form and PREA Forms must be completed and submitted to DRMProjectRequest@doc.state.ma.us no later than 1:00 PM on Wednesday, August 12, 2026.
The Background Clearance Form indicates that the Department of Correction will conduct a comprehensive background investigation that includes criminal record checks with local police departments, the State Police, the FBI, and the Massachusetts Board of Probation, as well as checks with past employers, neighborhood investigations, and interviews with character references. By signing the form, individuals authorize the Department and its agents to conduct these investigations and release them from any liability arising from the investigation process. The form serves as a prerequisite for site visits related to the dialysis room project at the Massachusetts correctional facility.
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Other files
| File | Type | Posted |
|---|---|---|
| PREA Form~1.pdf | ||
| Commbuys Vendor Registration.pdf | ||
| Business Reference Form~5.doc | DOC document | |
| A1 - MCI Shirley HSU Dialysis Room.pdf | ||
| EPP Form~11.docx | DOCX document | |
| WageSchedule_20260807150001.pdf | ||
| Amended RFR New Dialysis Room 08.12.2026.pdf | ||
| RFR New Dialysis Room~2.pdf | ||
| How to Create a Quote.pdf | ||
| Appendix A~4.docx | DOCX document | |
| Response Form A~13.pdf |
Show all 11
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Text version
The Commonwealth of Massachusetts Executive Office of Public Safety & Security
Department of Correction 50 Maple Street, Suite 3
Milford, MA 01757 Tel: (508) 422-3300 www.mass.gov/doc
MAURA T. HEALEY
Governor
TERRENCE M. REIDY
Secretary
KIMBERLEY DRISCOLL
Lieutenant Governor
SHAWN P. JENKINS
Commissioner
INSTITUTION/DIVISION:______________________________ DATE:______________________
NEW DOC EMPLOYEE________CONTRACT EMPLOYEE______________OTHER:______________________
PERSONAL DATA:
NAME:_______________________________________________________________________________________ Last Name First Name Middle Name
PREVIOUS NAME OR ALIAS: ___________________________________________________________________ (Maiden Name if Married)
RESIDENTIAL ADDRESS:_______________________________________________________________________ Number Street City/Town Zip
HAVE YOU EVER RESIDED IN ANOTHER STATE? _______ IF YES, WHICH STATE(s)? _________________
DRIVER’S LICENSE NUMBER/STATE:____________________________________________________________
DATE OF BIRTH:__________/__________/__________ PLACE OF BIRTH:______________________________
MOTHER’S MAIDEN NAME:_____________________________________________________________________
FATHER’S NAME:______________________________________________________________________________
I,____________________________________, hereby release, discharge, and exonerate the Massachusetts
Department of Correction, its agents, representatives, and any person so furnishing information, from any and all liability o f every nature and kind arising out of the furnishing or inspection such documents, records and other information of the investigations made by or in behalf of the Massachusetts Department of Correction.
I further understand that the Department of Correction will conduct a background investigation which will include a check with any past employers, a criminal record check with the local police department, the State Police, the FBI in Washington and the Massachusetts Board of Probation, a neighborhood check as well as interviews with my character references.
Signature:_____________________________________
GINA K. KWON
File details come from the government source that posted it. Updated .