CDCR 2189 - Incarcerated-Paroled Relative or Associate Notification.pdf
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- Attached to
- RFP C5612999
- Solicitation number
- C5612999
- Issued by
- California
About this file
This is a notification form issued by the California Department of Corrections and Rehabilitation (CDCR) for employees to report when they become aware of an incarcerated, youth, or paroled individual who is a relative or has a personal or business relationship with the employee. The form requires employees to complete sections detailing their own information, the inmate/youth/parolee's information including name, date of birth, and identification number, and to specify the relationship type. Employees must indicate whether the individual's presence at their institution or facility creates a conflict with their employment responsibilities, either through direct housing assignment or required work-related visits. The form mandates submission to the Institution Head, Superintendent, Deputy/Assistant Director, or Chief Executive Officer for review and approval.
The form implements compliance requirements under California Code of Regulations Title 15 Section 3406 and Department Operations Manual Section 33010.25.1. Upon completion, the original form must be delivered in a sealed confidential envelope to the Personnel Office for inclusion in the employee's Official Personnel File, with copies forwarded to the Case Records Unit for scanning into the inmate's Electronic Records Management System. For Division of Juvenile Justice (DJJ) cases, the form is placed in the youth's confidential field file. The approval process requires sign-off from applicable Chief Executive Officers and Institution Heads, who may recommend transfer of the inmate/youth/parolee if conflicts exist. All documentation maintains strict confidentiality protocols throughout the distribution and filing process.
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Text version
DEPARTMENT OF CORRECTIONS AND REHABILITATION STATE OF CALIFORNIA
INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION
CDCR 2189 (Rev. 07/18)
INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION
In accordance with the California Department of Corrections and Rehabilitation (CDCR) California Code of Regulations, Title 15 Section 3406, and Department Operations Manual Section 33010.25.1, this form must be completed each time an employee becomes aware of a relative or person with whom the employee has/had a personal or business relationship who has been committed or transferred to the jurisdiction of the CDCR.
TO BE COMPLETED BY THE EMPLOYEE.
EMPLOYEE INFORMATION
EMPLOYEE NAME (Last, First, Middle Initial) CLASSIFICATION INSTITUTION/FACILITY/PROGRAM AREA
WORK PHONE NUMBER (Include area code) WORK ADDRESS
INMATE/YOUTH/PAROLEE INFORMATION
INMATE/YOUTH/PAROLEE NAME (Last, First, Middle Initial)
DATE OF BIRTH (If known) IDENTIFICATION NUMBER (Can be retrieved at http://www.cdcr.ca.gov/Visitors/Inmate_Locator.html)
INSTITUTION/FACILITY/REGION RELATIONSHIP TO EMPLOYEE (Relative, personal, or business)
If the inmate/youth/parolee is transferred to your institution/facility/region, or is currently housed/assigned there, do you view his/her presence as conflicting with your employment caseload or responsibilities? Yes No N/A (I do not work at an institution/facility/region.)
If you are required to visit for work-related purposes (e.g., meeting, tour, temporary assignment) the institution/facility/region in which the inmate/youth/parolee is currently housed/assigned, do you view his/her presence as conflicting with your employment caseload or responsibilities?
Yes No
Explanation:
Employee’s signature Date
Submit this completed form to your Institution Head, Superintendent, Deputy/Assistant Director, or Chief Executive Officer.
APPROVALS
STEP 1 - IF APPLICABLE: TO BE COMPLETED BY THE CHIEF EXECUTIVE OFFICER.
Do you recommend this inmate/youth/parolee be referred for transfer? Yes No
Special instructions:
Chief Executive Officer signature Date
STEP 2 - REQUIRED: TO BE COMPLETED BY THE INSTITUTION HEAD, SUPERINTENDENT, OR DEPUTY/ASSISTANT DIRECTOR.
Do you recommend this inmate/youth/parolee be referred for transfer? Yes No
Special instructions:
Institution Head, Superintendent, or Deputy/Assistant Director signature Date
Distribution:
Original CDCR Form 2189 must be delivered in a sealed envelope marked “confidential” to the Personnel Office by the Institution Head, Superintendent, Deputy/Assistant Director or designee.
The Personnel Office must keep the original CDCR Form 2189 in the employee’s Official Personnel File. The CDCR Form 2189 shall be maintained in a sealed envelope marked “confidential” at the back of the file.
The Personnel Office must forward a copy of the CDCR Form 2189 in a sealed envelope marked “confidential” to the Case Records Unit.
The CDCR Form 2189 shall be scanned into the inmate’s Electronic Records Management System in the Confidential Section. For DJJ, the CDCR Form 2189 shall be placed into the youth’s field file in the confidential envelope.
http://www.cdcr.ca.gov/Visitors/Inmate_Locator.html
| EMPLOYEE NAME Last First Middle Initial: |
| CLASSIFICATION: |
| INSTITUTIONFACILITYPROGRAM AREA: |
| WORK PHONE NUMBER Include area code: |
| WORK ADDRESS: |
| INMATEYOUTHPAROLEE NAME Last First Middle Initial: |
| DATE OF BIRTH If known: |
| IDENTIFICATION NUMBER Can be retrieved at httpwwwcdcrcagovVisitorsInmateLocatorhtml: |
| INSTITUTIONFACILITYREGION: |
| RELATIONSHIP TO EMPLOYEE Relative personal or business: |
| Explain: |
| Date: |
| Special instructions: |
| Date_2: |
| Special instructions_2: |
| Date_3: |
| Clear Form: |
| Print Form: |
| Group1: Off |
| Group2: Off |
| Group3: Off |
| Group4: Off |
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