Editable_Packet.pdf

Application Packet for Access Notification Checklist

□ Completed Application for Access to Minnesota Correctional Facilities/Sites for Non-DOC Personal (3 pages)

□ Completed Photo and Visual Images Notice and Consent

□ Sexual Misconduct with Offenders (PREA) Handout (for individual)

□ Completed Sexual Misconduct with Offenders

□ Completed Disclosure of Offender Association (front/back)

□ If applicable; MN Department of Corrections Request for Communication with Individual Offender

□ If applicable; Contractor Tool Inventory

□ Copy of a Valid State ID, Passport (only if out of country), or Military ID.

Once all these have been completed please send full packet to SHKFacilityAccess@state.mn.us for processing.

*Entire Packet should be submitted with Access Notification at least 3 business days prior to event. Please do not submit until the full packet is complete.

Thank you!

mailto:SHKFacilityAccess@state.mn.us

Page 1 of 12 300.020A (12/2020)

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? _______________________________________________________________

Page 2 of 12 300.020A (12/2020)

Have you EVER been convicted of a felony? No___ Yes___

Have you EVER served time in a MN DOC facility? No___ Yes___

Do you have ANY charges pending against you? No___ Yes___

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? No___ Yes___

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

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

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

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

(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

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.

Page 3 of 12 300.020A (12/2020)

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 the facility address on the front of the form.

Official Use Only

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

Staff initials / Date Staff initials / Date 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:_______________________

Page 4 of 12 300.020A (12/2020)

Photo and Visual Images Notice and Consent

Photographs are considered private data under the Minnesota Governmental Data Practices Act (MGDPA), Minnesota Statutes Chapter 13. The DOC is providing you with the following notice regarding photographs and visual images collected by DOC representatives.

Identification Card/Photos: The purpose of your photograph on your identification card and/or its retention within an access control system is so, contractors, volunteers, interns, and visitors may be visually identified in order to enhance facility safety and security. Your photo is electronically stored and is accessible by those who have a business need to access it. While you may refuse to be photographed for your identification card and/or the access control system, facility security requires the use of photo ID’s and the access system and the consequences of refusal may result in denied access to DOC facilities and/or Central Office.

Informed Consent to Release Private and Confidential Data

I _____________________________, (print name), a (please check appropriate box) contractor, volunteer, intern, or visitor, have read and understand the above Tennessen Warning Notice. I hereby authorize and release representatives of the DOC to use my photograph consistent with the information above. This photograph is related to my access and security while on DOC or State premises. This release has no expiration date.

Signature:________________________________________ Date:______________________ Requested – Not Required

END THE

SILENCE

Zero Tolerance for Sexual Abuse and Sexual Harassment:

Prison Rape Elimination Act

(PREA)

RIGHT TO REPORT

If you, or someone you know, are experiencing sexual abuse or sexual harassment, the

Department of Corrections wants to know.

We want you to report right away! Why?

• We want to keep YOU safe; it is our job! It is your right to be free from sexual abuse and sexual harassment.

• We want to investigate the reported incident.

• We want to hold the perpetrator accountable for his/her actions.

• We want to provide YOU with relevant information and support services.

How to Report

The Department of Corrections offers multiple ways to report sexual abuse and sexual harassment:

• Telephone: Rape, Abuse, and Incest National

Network RAINN *77

• Report to any staff, volunteer, contractor, or medical or mental health staff.

• Submit a grievance or sick call slip.

• Report to the PREA Coordinator or the facility PREA Compliance Manager.

• Tell a family member, friend, legal counsel, or anyone else outside the facility. They can report on your behalf by calling the DOC

Sexual Abuse Helpline at

651-603-6798.

• You also can submit a report on someone’s behalf, or someone at the facility can report for you.

External Reporting Option

You also can make a report to Rape, Abuse, and

Incest National Network at *77. This resource is located outside the Department of Corrections and you can remain anonymous upon request.

IF YOU ARE ABUSED

Support services are available from a Victim

Advocate and can be reached at 651-361-7666.

What to Do If You Have Been Sexually Abused

• Tell a staff member as soon as possible.

• Seek medical attention BEFORE you shower, eat, drink, change clothing, brush your teeth, or use the bathroom.

• Share as much information as possible when answering questions to assist with the investigation.

NOTICE FOR FAILURE

TO REPORT

Anyone who engages in, fails to report, or knowingly condones sexual harassment or sexual abuse of an Incarcerated

Person/resident/detainee shall be subject to disciplinary action and may be subject to criminal prosecution.

Facility Name Goes Here

Agency Name Goes Here

PREA Coordinator:

Coordinator’s name | (XXX) XXX-XXXX

PREA Compliance Manager:

Compliance manager’s name | (XXX) XXX-XXXX

The Challenge Incarceration Program does not tolerate any form of sexual abuse or sexual harassment. The goal of this facility is the safety of the Incarcerated Person. The facility will hold accountable any persons found to have committed any form of sexual abuse or sexual harassment against another person.

If any of the information presented here is confusing, or you have questions about something that may be happening to you, ask a staff person you trust.

Call the MN DOC Sexual Abuse Helpline

651-603-6798.

Select Collect Call option. It is a FREE call from any DOC pay phone.

On the MN DOC public website, anyone can email or mail the statewide:

PREA Coordinator MCF- Lino Lakes

7525 Fourth Avenue Lino Lakes, MN 55014

NO

NO

MEANS

ZERO TOLERANCE

The Department of Corrections has a zero-tolerance for sexual abuse and sexual harassment. What does this really mean? It means that YOU have the right to be free from sexual abuse and sexual harassment by anyone at the facility, including an Incarcerated Person, staff, volunteer, or contractor. No one has the right to sexually abuse or sexually harass you.

No one.

What Is Sexual Harassment?

• Repeated and unwelcome comments or gestures of a sexual nature, including demeaning references to gender, sexually suggestive or derogatory comments about body or clothing, or obscene language or gestures.

• Repeated and unwelcome sexual advances;

requests for sexual favors; or verbal comments, gestures, or actions of a derogatory or offensive sexual nature.

What Is Sexual Abuse?

• Forced or coerced sexual intercourse or sexual contact when the victim does not consent or is unable to consent or refuse.

This may include the use of fear or threat of physical violence, psychological intimidation, bullying, and physical force.

What is staff voyeurism?

An invasion of privacy of Incarcerated Person by a staff, contractor, or volunteer for reasons unrelated to official duties.

Your complaint will be handled respectfully and confidentially.

Examples of Staff Voyeurism

• Watching an Incarcerated Person use the toilet, shower, or change clothes.

• Requiring an Incarcerated Person to show his/her buttocks, genitals, or breasts.

• Taking pictures of an Incarcerated Person’s naked body or toilet use.

Tips for Avoiding Sexual Abuse and Sexual Harassment

A victim is never to blame for being attacked, but these tips may help you lower your risk of sexual abuse or sexual harassment.

• Pay attention to your surroundings.

• Always carry yourself in a confident manner.

• Do not accept gifts or favors from others.

They usually come with “strings attached” or future paybacks, including sexual favors.

• Do not accept an offer from another resident to be your protector or “friend.”

• Find a staff with whom you feel comfortable discussing your fears and concerns. Confide in him/her if you feel threatened; or call the

DOC Sexual Abuse Helpline 651-603-6798.

• Be alert! Do not use contraband such as drugs or alcohol, as they will weaken your ability to be alert and make good choices.

• Be direct and firm when others ask you to do things that you do not want to do.

• Do not give mixed messages to others regarding your wishes for sexual activity.

• Choose your acquaintances wisely.

Page 7 of 12 300.020A (12/2020)

Sexual Misconduct with Residents Prison Rape Elimination Act [PREA] Information

I acknowledge that I have received training, policy and specific written details outlining sexual misconduct with Residents and the Prison Rape Elimination Act federal laws. I will fully review the policy, materials provided and ask questions, if needed, for understanding of the information provided.

I understand that Minnesota Department of Corrections [DOC] policy specifically forbids any activity associated with or that promotes acts of sexual conduct, sexual abuse, including sexual harassment between residents and DOC staff. In this definition, “staff” includes DOC employees, contractors, representatives, interns, or volunteers of the DOC as well as staff from other federal, state, or local jurisdictions. “Resident” is someone confined in a correctional facility, contracted detention facility, halfway house, or under supervision in the community.

I further understand that sexual misconduct is against the law under M.S. 609.344 and 609.345.

signature date printed name work location

Electronic copy of completed form to Training Coordinator, and original to staff/volunteer/contractor/intern’s supervisor.

Page 8 of 12 300.020A (12/2020)

DISCLOSURE OF OFFENDER ASSOCIATION

All employees, student workers, volunteers, interns, and contractors are required to disclose any personal or professional association(s) they have or have had with current offenders, offenders whose sentences were discharged within two years, or family (spouse, child, grandparents, or siblings) of current or former offenders. DOC Policy 103.223. If you are unsure of the need to disclose, complete a form or ask for clarification from Human Resource Management personnel.

Date: __________ Name: _________________________________________ Full Name

Please check one:

____ To the best of my knowledge I have no known personal or professional associations with current or former offender(s) or with the family of current or former offender(s).

____ I have or have had personal or professional associations with the individual(s) identified below. List the names of all offenders, former offenders, or family members of current or former offenders here and complete a Request for Approval of Offender Association for each individual listed.

Employee/Student Worker/Volunteer/Intern/Contractor’s Signature

Page 9 of 12 300.020A (12/2020)

REQUEST FOR APPROVAL OF OFFENDER ASSOCIATION

Your name Date

Please provide the following information about the offender or family member of the offender.

Add any comments you feel are necessary to explain the circumstances. Return the completed form to your supervisor.

Full name of offender:

Facility or location of offender:

Describe the nature and frequency of your association with the offender or give the name of the offender’s family member and describe the nature of your association with him or her:

Do you wish to maintain contact with the offender or family member? ____ Yes ____ No

If yes, please explain the type of contact you have including how often below: (E.g. phone contact, visiting, mail contact, depositing funds in offenders account, family gatherings and how often this occurs).

Signature Date

Warden or Business Unit Manager Review:

________ Approved _________ Disapproved

Signature Date

OSI USE ONLY

OID Facility

Release Date Date entered by OSI:

By:

300.040C (5/2015)

MN Department of Corrections Request for Communication with Individual Offender

Requester’s Last name First name Middle

Group/Organization:_____________________________________________________________

Reason for requesting communication:

Volunteer in a structured transitional program Professional purpose (lawyer, religious representative, re-entry, etc.)

Mentor Other

Explain:______________________________________________________________________________________

Type of communication being requested:

Letter Phone O-mail E-mail All

Contact information to be disclosed to the offender for the purpose of communication:

Home address Work address Home phone Work phone Cell phone E-mail

Home Address:_______________________________ Home phone:____________________________ ______________________________ Cell phone:______________________________

Work address:________________________________ Work phone:____________________________ _________________________________ E-mail address: __________________________

Offender’s Last name First OID

-------------------------------------------------------Facility Use Only------------------------------------------------------------- Volunteer Coordinator Recommendation:___________________________________________________

Volunteer Coordinator:____________________________________ Approved Denied Signature

Warden/Designee:_______________________________________ Approved Denied Signature

CC: OSI

Warden

301.040-2BSHK

Minnesota Department of Corrections Minnesota Correctional Facility - Shakopee

CONTRACTOR TOOL INVENTORY

DATE: COMPANY NAME:

CONTRACTORS NAME:

TIME

IN:

ESCORTING

STAFF:

TIME OUT: ESCORTING

STAFF:

PAGE OF

(TOOL CLASSIFICATION WILL BE DETERMINED BY STAFF CONDUCTING INVENTORY)

QTY. TOOL/DESCRIPTION In Time Initial Exit

Time Initial

DISTRIBUTION: Original: Tool Control Lieutenant. Copies: Escort Staff, Contractor/Tool Box *** Completed form must be filed in the Tool Inventory Book at the Construction Office when job is completed ***

Page 12 of 12 300.020A (12/2020)

Please include a photocopy of your

Driver’s License, Valid State ID, Passport, or Military ID.

Thank you!