Exhibit_A5_ADMIT_Packet.pdf

Page 2 of 8 300.020A (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 3 of 8 300.020A (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 4 of 8 300.020A (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 1 of 8 300.020A (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

Page 5 of 8 300.020A (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 6 of 8 300.020A (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:

Page 7 of 8 300.020A (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 8 300.020A (12/2020)

Please include a photocopy of your

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

Thank you!

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Te ll a fam ily m em b er, frien d

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If an y o f th e in fo rm atio n p rese n te d h ere is co n fu sin g, o r yo u h ave q u estio n s ab o u t so m eth in g th at m ay b e h ap p en in g to yo u , ask a staff p erso n yo u tru st.

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W h at Is Se xu al H arassm e n t?

R ep eated an d u n w e lco m e co m m en ts o r gestu res o f a sexu al n atu re, in clu d in g d em ean in g refe ren ces to gen d er, sexu ally su ggestive o r d ero gato ry co m m en ts ab o u t b o d y o r clo th in g, o r o b scen e lan gu age o r gestu res.

R ep eated an d u n w e lco m e sexu al ad van ces;

req u ests fo r sexu al favo rs; o r verb al co m m en ts, gestu res, o r actio n s o f a d e ro gato ry o r o ffen sive sexu al n atu re.

W h at Is Se xu al A b u se

Fo rced o r co erce d sexu al in te rco u rse o r sexu al co n tact w h e n th e victim d o es n o t co n sen t o r is u n ab le to co n sen t o r refu se.

Th is m ay in clu d e th e u se o f fe ar o r th reat o f p h ysical vio len ce, p sych o lo gical in tim id atio n b u llyin g, an d p h ysical fo rce.

W h at is staff vo ye u rism

A n in vasio n o f p rivacy o f In carcerated

P erso n b y a staff, co n tracto r, o r vo lu n te er fo r reaso n s u n related to o fficial d ties.

Y u r co m p lain t w ill b e h an d led re sp e ctfu lly an d co n fid e n tially.

Exam p le s o f Staff V o ye rism

W atch in g an In carcerated P erso n u se th e to ilet, sh o w e r, o r ch an ge clo th es.

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In carcerate d P erso n to sh w h is/h er b u tto cks, gen itals, o r b reasts.

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Tip s fo r A vo id in g Se xu al A b se

Se xu al H arassm e n t

A victim is n ever to b lam e fo r b ein g attacked b u t th ese tip s m ay h elp yo u lo w er yo u r risk o f sexu al ab u se o r se xu al h arassm en t.

P ay atten tio n to yo u r su rro u n d in gs.

A lw ays carry yo u rself in a co n fid en t m an n er.

D o n o t accep t gifts o r favo rs fro m o th ers.

Th ey u su ally co m e w ith “strin gs attach ed o r fu tu re p ayb acks, in clu d in g se xu al favo rs.

D o n o t accep t an o ffer fro m an o th er resid en t to b e yo u r p ro tecto r o r “frien d

Fin d a staff w ith w h o m yo u fe el co m fo rtab le d iscu ssin g yo u r fe ars an d co n cern

s. C o n fid e in h im /h er if yo u fee l th reate n ed ; o r call th e

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B e alert! D o n o t u se co n trab an d su ch as d ru gs o r alco h o l, as th ey w ill w eaken yo u r ab ility to b e alert an d m ake go o d ch o ice s.

B e d irect an d firm w h en o th ers ask yo to th in gs th at yo u d o n o t w an t to d o

D o n o t give m ixe d m essages to o th ers regard in g yo u r w ish es fo r sexu al activity.

C h o o se yo u r acq u ain tan ces w isely.

ADMIT PREA.pdf