MA DOC - Clearance Form.pdf

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:_____________________________________

+ Massachusetts Department of Correction

Volunteer and Contractor Training and Acknowledgement of Prison Rape Elimination

Act (PREA) - Attachment IV

I have been informed of and understand each of the following specific items about the PRISON RAPE ELIMINATION ACT (PREA) of 2003 listed below:

(1) Federal law specif ic to incarcerated persons, the Prison Rape Elimination Act (PREA) of

2003, requires that the Department of Correction (DOC) take steps to prevent staf f -on inmate and inmate on inmate sexual contact of any type f rom occurring in or around DOC facilities and/or property.

(2)

The Department has zero tolerance toward all forms of sexual abuse and sexual harassment and is committed to preventing, detecting, and responding to such conduct as outlined in 103 DOC 519 - SEXUALLY ABUSIVE BEHAVIOR PREVENTION AND INTERVENTION POLICY. The Department embraces the standards set forth by the National Prison Rape Elimination Commission and the American Correction Association for all state correctional jurisdictions.

(3)

State and Federal law specif ic to incarcerated persons forbids sexual contact of any type or kind whatsoever by an employee/volunteer or contractor in or around DOC facilities and/or property

(4)

Sexual misconduct between an employee/volunteer or contractor and an inmate is forbidden and may result in discipline up to and including termination and referring for prosecution Department employees, contractors, volunteers and inmates who engage in sexually abusive behavior. Sexual misconduct can consist of conversations, gestures, or correspondence of a sexual nature. This includes demeaning references to gender or sexual preference, or sexually suggestive or derogatory comments about body or clothing, or obscene language or gestures. Sexual misconduct also includes voyeurism which is an invasion of an inmate’s privacy by peering at an inmate in private situations outside of those required by supervisory or security policies and procedures.

(5)

I have a duty to report any sexual misconduct between an employee, volunteer or contractor and an inmate that I observe or have reason to believe occurred and must report it to the Shif t Commander as required. If I fail to do so and such is proven pursuant to policy, there could be disciplinary action up to and including termination and/or criminal action.

Print Name Company

Signature Date

Massachusetts Department of Correction

Capacitación de Voluntario y Contratista y Reconocimiento del Acto de Eliminación de

Violación en Prisión (Prison Rape Elimination Act PREA)- Adjunto IV

Yo he sido informado/a de y comprendo cada uno de los artículos específicos acerca del ACTO de ELIMINACION de VIOLACION en PRISION del 2003 (PRISON RAPE ELIMINATION ACT, PREA) listados más abajo:

(1)

La ley federal específ ica a personas encarceladas, el Acto de eliminación de Violación en Prisión (Prison Rape Elimination Act,PREA) del 2003, requiere que el Departamento de Corrección (DOC) tome pasos para prevenir que ocurra contacto sexual de personal sobre preso y de preso sobre preso de cualquier tipo en o alrededor de facilidades del DOC y/o propiedad .

(2)

El Departamento tiene cero tolerancia hacia todas las formas de abuso sexual y acoso sexual y está comprometido a prevenir, detectar, y responder a tal conducta como delineado en 103 DOC 519 – POLITICA DE PREVENCION E INTERVENCION DE CONDUCTA SEXUALMENTE ABUSIVA. El Departamento abraza los estándares establecidos por la Comisión Nacional de Eliminación de Violación en Prisión y la Asociación Americana de Corrección para todas las jurisdicciones correccionales estatales .

(3)

Ley Estatal y Federal específ ica a personas encarceladas prohíbe cualquier tipo o clase de contacto sexual por un empleado/voluntario o contratista en o alrededor de facilidades del DOC y/o propiedad.

(4)

Mala conducta sexual entre un empleado/voluntario o contratista y un preso/a esta prohibida y puede resultar en disciplina hasta e incluyendo terminación y referir a enjuiciamiento a empleados del Departamento, contratistas, voluntarios y presos/as que participan en conducta sexualmente abusiva. Mala conducta sexual puede consistir de conversaciones, gestos, o correspondencia de una naturaleza sexual. Esto incluye referencias degradantes al género o preferencia sexual, o comentarios sexualmente sugestivos o degradantes acerca del cuerpo o vestuario, o lenguaje obsceno o gestos. Mala conducta sexual también incluye voyeurismo que es una invasión de la privacidad de un preso/a por medio de mirar a un preso/a en situaciones privadas fuera de esas requeridas por políticas y procedimientos de supervisión o seguridad.

(5)

Yo tengo el deber de reportar cualquier mala conducta sexual entre un empleado, voluntario o contratista y un preso que yo observe o tenga razón de creer que ocurrió y debo reportarlo al Comandante del Turno como requerido. Si yo fallo de hacerlo así y lo tal es probado de acuerdo a la política, podría haber acción disciplinaria hasta e incluyendo terminación y/o acción criminal.

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