Brown Card Instructions – Kairos, CMF Vacaville

Brown Card Instructions – Kairos, CMF Vacaville
Version 2.0: 09/19/12
This packet can be mostly completed on your computer (using Adobe Reader version 8.0 or higher), saved for future reference, and then printed (or simply printed and filled out completely by hand). Please note that the eye and hair color on Form #2 must be circled by hand. Don’t forget to do so before mailing your packet. For an example of a completed set of forms, please refer to the “Fictitious” file version of the Brown Card application packet. Completing the Brown Card forms There are 11 forms in this packet. Please complete them using the “Fictitious” file version as an example. Most of the fields on the forms are self‐explanatory. However, some important points include: 


Form #1 (REQUEST FOR NON‐EMPLOYEE IDENTIFICATION CARD): o First Time Volunteers: If this is an application for your first Brown Card at CMFV, be sure and check “New” and respond to Question 2(A). o Veteran Volunteers: If you have had a Brown Card at CMFV in the past, even if it has expired, check “Renewal” and fill in the EXP DATE field (enter the month/year if you don’t know the exact date or say “Unknown” if you don’t know when it expired). Be sure and respond to Question 2(B). Form #2 (PERSONNEL IDENTlFICATION CARD INFORMATION) o Eye and Hair colors cannot be indicated electronically on the form. Be sure and circle them after you have printed the form. o DO NOT SIGN or DATE until you have received your Brown Card. Form #11 (EMPLOYEE TUBERCULIN SKIN TEST (TST) AND EVALUATION) o Very important: This form is required and must be completed and submitted with your Brown Card packet. You cannot substitute a “generic” form from your health care provider. Please make sure your health care provider completes and signs the appropriate sections for administering the test and reading the test. o The “Fictitious” example intentionally does not include the entire form because sections 2‐5 are very specific to your health situation. Please make sure they are completed accurately.  Section 1 must be completed with your personal information  Section 2 must indicate whether you have prior significant TB tests and/or TB disease.  Section 3 must indicate the specifics of the TST administration and include the name and signature of the person administering the TST.  Section 4 must indicate the “reading” of the test.  Section 5 and 6 are only completed if they apply.  The final section must indicate that the “Employee is Free of Infectious Tuberculosis” and must be signed by the evaluator. Brown Card Instructions – Kairos, CMF Vacaville
Version 2.0: 09/19/12
Delivering the completed forms: 



Be sure and deliver the completed forms as soon as your TB test is completed. Don’t let the packet hang around the house. The prison wants the TB test to be no older than 30 days when the packet goes through the approval process. Make sure the appropriate forms are hand‐completed where necessary, signed and dated (including Form #11, the TB form). Make a copy of the set for your records in case the originals get lost in the process and to use for completing your renewal application next year. First Time Volunteers: Mail your original  Veteran Volunteers: Mail your original packets packets to: directly to the prison: Jim Devlin Landon Bravo 4632 Park Milford Pl Community Resources Manager San Jose, CA 95136 California Medical Facility, Vacaville P.O. Box 2000 Once mailed, email Jim to alert him that you Vacaville, CA 95696‐2000 have mailed the packet to him. Jim’s email address is jim@aquaheating.com. Do not email the packet to Jim. Mark “Kairos” in the bottom left‐most corner of the envelope. Jim will double‐check your packet for completion and then forward it on to the prison. If you are joining a Kairos team, you may also be requested to send an email to the Security Director for the team who will help coordinate all the Brown Cards for the Weekend. Once mailed, email Landon to give him a heads up that you have sent the packet. His email is Landon.Bravo@cdcr.ca.gov. Do not email the Brown Card packet to Landon. Also email Jim Devlin to alert him that you have mailed the packet to Landon. Jim’s email address is jim@aquaheating.com. What to expect once your Brown Card packet is received by the prison Since 2011, the probability of getting a Brown Card application packet processed reliably and quickly has become quite high. You will need to plan on making two trips to the prison. 
Fingerprints and Photograph: Within 3‐4 weeks after submission, you will probably get a phone call from someone in prison personnel that your application packet has been approved (or not). Assuming it has been approved, you will be requested to come to the prison to have your fingerprints (for first timers) and photograph taken. Make sure you connect real‐time with a personnel person and make an appointment to have your fingerprints and photograph taken. IMPORTANT: If you have not heard from the prison within four weeks of mailing your packet, please give Jim Devlin a call at 408‐482‐0079 to notify him of the delay. 
Brown Card Acceptance: Once you have your fingerprints and photograph taken, it usually takes about a week for the prison to complete your Brown Card. You should receive another call to come back and sign for the card. NOTE: Some volunteers have made arrangements with Prison Personnel to sign for their Brown Card at the front gate when they first arrive for the Weekend Event. This is risky and not recommended. Some folks who made these arrangements have arrived at the gate and the Correctional Officer is unable to find their card and they cannot get into the prison. It is strongly recommended that you make a separate trip to the prison during normal business hours and meet with someone from Prison Personnel to sign for your Brown Card. 
Brown Card Storage: Once you sign for your Brown Card, it will be stored at the Front Gate. You will trade your California ID for it when you enter the prison. i
CONTRACTOR
VOLUNTEER
CALIFORNIA MEDICAL FACILITY
VACAVILLE, CALIFORNIA
fmQlJEST FOH NON-EMPLOYEE IDENTIFICATION CARD
Please Pn
PI
NAM_~______~ __ ~.~~ ___ ~~..... ______~ ___~~__~
NEW
ALiAS (
TB. CERTIFICATE i~IOME
ADDRESS
Check
RENEWAL EXPDATE BUSINESS ADDRESS
Place of Birth _ _ _ _ _ _ _ _ _ _ _ _ _ __
Sex:
Eyes ~________
M/F
Social SecllI'iry No:
Height . . _ _ _ __ Weight _______
-----.'~---
Driver's License No: ----------- State: - - - - - Exp Date: - - - - -
J. Do YOli visil undlor correspolld with any inmate(s) in Califomia Department of Corrections') Y
If yes, e,'(plnin fllJly and proyide inmnte(s) name(s) and CDC number.
2, (AJ
(BJ
NEIl": Huve
YOLI
ever been arrested/convicted of an offense') Y
RENEWAL 0 NL Y: Have
Y
YOLI
N
N
been arrested/convicted of an offel1se during the past 12 months:
N
IF YES: Complete tbe attached Law Enforcement Qllestionnire, CDC 1951
3, Are you on parole/probation') Y _. N _~_ If yes, mime of Pm'ole Agent/Probatioll Officer and region
Attach permissoJ1 slip of agent/officer.
4. Are yOll discharged rrom prison or parole'! Y_ N _If yes, date _____, !1nl1le of institution
__ .~. ~. ____ . ~___.____~___, and you 11111st oblain and aunch permission of the Wnrden eMF,
Attached is a Diges! ofLaw5 Related to Associatioll with Jlrisonlnl1lnles,
Signatureof Applicant
Dnte
eM F!Spollsor/SupervisOI N <1me
Signnturc IDnte
EXT
Depnrtment Helld Name
Signa lure I Da Ie
EXT
X
51A "J"E. OF CAL1FORNtA
DEPARTME:,rr OF CORRECTIONS
PERSONNEL IDENTlFICATIONCARD INFORMATION
2
CDC B94-A (1/99)
------------------~P~L~EA~S~E~TYP~~E~O~R~PRmT~~A~L~L-E~N-TIU---ES--EX--C-EP-T--SI-G-N-A-T-U-RE--.----------------­
IF YOUR CARD BECOMES LOST OR STOLEN, REPORT TIIIS IMMEDATELY IN WRITING
TOTHE APPROPRIATE WARDEN, REGIONAL PAROLE ADI\1.INISTRA TOR, OR DIVISION ADMl1ilSTRs,. TOR
I
I
NAME (FIRST. LAST. 1\'11):
1
CL\.SS mLE
----­
'~----~EXP~ffiA~~TIUO~N~D~A~TrE-----,------~B~!~R~TH~D~A~T~E------~1--------~H~E~l~G~HT~--------~------~\V~.E~I~G~H=T---------1 (pmonoel Use Only)
I EYE COLOR
I
.
nu.CK BLUE
(CIRCLE OI'lE)
BROWN
GRAY
GREE:-I
I
,'tfl:"L nco LOR PINK UJ'IR10WN
AFFILIA T£ ,'1",'1-([
I
SE.::X-::-(-=C=IR-C":"LE~ON.Ej
'\t..l,.LE
HAZEL
,'l-LJ,.ROQN
H.-UR COLOR
(CIRCLE Ot!'E)
BALD
BLONDE
I
BLACK
WHITE
. {. C.J,.UFORNlA DRIVERS LI01D;i
i
GR.l. Y
RED
SA..:my
L'Nk,"IOWl'l
I
.
BADCE:: (IF p£'.J. CE OFFICER)
FEMALE
I
TYPE OF ill CARD TO BE ISSUED:
o
o
RElIR:?D NON-CUSTODY
o PEACE OFFICER
o RETIRED PEACE OFFICER
CJ
FMPORARY (TAU,LT, Vendor,' etc)
[] CfTfZ5N ADVISORY COMMITTE:E
oX
COMMUNITY VOLUNT=E:R
NON·CUSTOOY EMPLOYEE
TO BE CO}fPLETED BYE}fPLOYEE
I
I
-~~--­
COLLECTn'E BARGAL'IfNG D£SfC;'<ATIO.'l
DRANK & FlU:
o
SUP::RVISORY
o MANAGERIAL
o CONFIDENTIAL
UPON RECEITT OF ID
CARD
J! 15 unlawful 10 :>nng alconoi, drugs. weaoons, ex:!cslves. (ear gas or (ear ;as weapons onto prison proper.; '.vi/noue pro:;er aulhor.::auon. Any err:ployee
ootalning lor, or celivering (0 an Inmate or parclee any a!c~hQli.: ;:;re;:;ar:;licns :f any :~Ind, or a drug 01 any t'!oe. will be subjec: Ie dismissal frem state
services and to crililin al prosec:Jlion,
'::mployees must not take or sene, eitfler:o or frem any inmate. any '/ereal or wnt:en message, literature or reacing matter, or any iterr:.
except as necessar/in. caIT'jmg au( the emplo~ee 5 asslgr1ec (JUCles,
':::nplcyees snaIJ-n-Oidirec:T:/oTindire::::ly (idCe, ;;ar;ef;-ie~..;;l:lermSe enga~e m
(0 be a relative of an Inma!!! Of parolee. ar;:c:e or substances
transac.:cr,G '{'lith any ;nmats ..:Jar~lee or perscn kncwn
by the employee
~',c .eli':::!iO;tee ,cr ~erson snail :eave igdtion swUc..... es· unlecxe,:: woile :n :r.s~itut:on grour.cs. Venjc:e keys mus: r~ct be len io an:1 'una~=r:ce-: '1enic!e, U~cer no ~;rC:.lr.1s:anc~s may alc:;nolic =:leverages, orugs. "Jr f:rear;-;;z, ";)~f ;1CiiS, "~::,::,\;ricr,. ,'~;r :J::1et'iter:;::;. wn;~; -.are
:iI.e:;.ili ,cr tJ:'rE3ien the sc::.:rHy 0; the ins:iltHicr., be left in any unattended venlc!e, ay 2ntenng.uP9n Department grounds, you :::u:ser.::o Ihe 5::ar:::J of your ;>ers;m, prcper.( and '/!!mc!e.
?ersons wno are no! employed by Ihe Depar.mer.: of Cor.e=:ons. bl:1 'imowcrl; or viSIt al any Department facility must cbs!!;,,!! all rules, :egularions and laws governing the conduc: of employees al thaI facility. Failur~ (0 do sc r.1ay lead :0 ex:::tusion from Departmen! ta~:iihes. It is your duly 10 read and abide by the Direc:or's r.;les wr.ile worl;ing a! !he Depan:ment':i facilities. I have receIVed and reviewed my assigned identi:ca(ion c:l(C and founc all entr:es :0 De ccrrec..
PRIVACY 5TA12!vlENT
The in/ormation ?;ac.:ices Ac:.o( 1977 (Civil C::ce Sec:ion /798.17) re-;;:.:ires tnat (he following nouce be provice~ wnen coile:::ing peiScr.al iniOfTl1a:':o n from
indivic:Jals:
AGENCY RE5?ONSI8L::: ;:OR MAINT::NANC::. California De;:;ar.menr -:;i CJr.ec.ions, Office of ?ersonnel Managemenl.
P.O. 30x 942SeJ, Sac:-amen[O. CA 9~23}"OCOl
AUTHORITY: Deparunent Operaticr.s ),Ianual 3~:::on J 1<::7:' es:a::iisnes :he ,71e!hocs ant: ;Jroce·::.:res
persons ::!oing ::t:slness in Depa=le~: ;acilities.
:0
I
I
BROWN.
mair:tain idemificJ::cn ci emc!cye9S or
F.XPTRATTnN nAT]:'
STATE Of' CAJ..1YORNlA
DI!PARTMENT OP CORRECTION
Dl8T:
ORIG - OFFICIAL PF.J!80NNEL FILE
COPY. EMPLOYEE'S SuPERVJ30R
EMERGENCY NOTIFICATION INFORMATION
CDC 894 (9192)
THIS INFORMATION WILL BE KEPT CONFIDENTIAL IN YOUR OFFICIAL PERSONNEL FILE AND YOUR SUPERVISOR'S EMPLOYEE RECORDS AND WILL BE USED FOR EMERGENCIES ONLY, PLEASE BE SURE TO UPDATE TIllS INFORMATION SHOULD IT CHANGE. EMPLOYEE'S NM.a: (UST, FIRST, MIDDLE) IDCW, SECURITY NUMBER
(PROVJSION IS VOLUNTARY,
REQUESTED FOR !D PURPOSEB ONLY)
HOM}; ADDRESS: (STllEET NUMBEl!AND NAMI:, CITY AND W' CODE) HOME TELEPHONE NUMB!.!.!l
I-:M]'LOYED (FACILITY AND UNm WORK PHONE NUMBER
W::::;::;:",;~:i;;;;:!Mt:!;;r:m:@'j:;P'DEASEdNDICATEiPERSONtstTOm·g:NOTIFIEmfINJJA'SEibE~EMER0ENC¥~~i:;;i(;¥(':::.:::::::;;':':::i:;;:i/~{i:i:::
NAM~
ADDHESB
NAM.£:
PEllSONAL PffYSIClAN'S NAME
SPECIAL INSTRUCTIONS (l}' APPLICABLE)
wonK n;LEPtiONE NUMBER
s:3
S1'An: OF CALIFOR..'IL\.
DEPAR1'ldENT OF CORRECTIONS
APPliCANT NOTIFICATION AND ACKNOWLEDGEMENT
C::OC 1199 (8189)
If appointed to any position with the California Department of Corrections, you will be fingerprinted for the purpose of obtaining a criminal records check from the Department of Justice. '. If you areapproved to workat the,Department ofCorrections and you are arrested or corivictedOf any violatioris of
. the law,You must promptly notify your superv~s{}r. Further, if you become aware that any relative or close friend
.has been committed to or transferred to the jurisdiction of the California Department of Corrections, you must
report the matter to your supervisor. (Director's Rules Sections 3406 and 3411.)
I,-,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ have read and acknowledge the above information.
PRINT OR TYPE APPLJCANiB NAME
.
'
..
t:.
'"
STATE OF CAliFORNIA - GENERAL SERVICES HUMAN RESOURCES
EMPLOYEE ASBESTOS NOTIFICATION
STD. 250 (REV. 3/2002)
Effective January I, 1989, Assembly BiIlJ7J3, Chapter 1502, Statutes ofJ988,Heaith and Safety
Code, Subsection 25915 et seq., regLrires State agencies which occupy buildings constructed prior to
1979, and know of the presence of asbestos-containing materials CACM) in the building, to provide
\vriHen notification to employees within 15 days of knowledge. Employees newto the building shall
be provided this information within 15 days of commencing work in the building. Please refer to the
State Administrative Manual Section 2591.
Airborne asbestos levels in buildings are much lower than those in industrial workplaces where . serious health effects sllch as lung cancer and asbestosis have been observed. However, it is important for employees to follow proper work practices to minimize the potential for disttrr.bing ACM. Avoid touching asbestos materials on walls, ceilings, pipes, or boilers. Do not drillholes, hang plants or other objects from waUs/ceilings made ofACM. Do not disturb ACM when replacing light bulbs. If you find ACM that has been damaged, report it to your supervisor. Do not disturb damaged asbestos material or asbestos debris. Only persons authorized and properly trained should perform any work, which may disturb asbestos materials.
Asbestos-containing materials pose no threat to your health L1nless fibers become airborne due to
material aging, deterioration, or as the result of some damage. Asbestos conditions may vary, and
\-vhere ACM have been identified in State building surveys, the materials were generally in good
condition, ·enclosed, encapsulated, or of a ·type not likely to release fibers unJe5s disturbed.·
'
...
Any employee may review the asbestos survey report, results of bulk sampling, or air monitoring
conducted in this building. All asbestos-related data will be available during nonnal business hours
at the building mannger's office (Plant Operations Department).
1, ______________, have read and received a copy of the Employee Asbestos
Notification.
Employee Signature
DISTRIBUTION: ORIGINAL - PERSONNEL FILE; COPY - EMPLOYEE
Date
DEPARTMENT OF CORRECTIONS AND REHABILITATION
STATE OF CALIFORNIA
SUPPLEMENTAL APPLICATION
FOR NONPEACE OFFICER CLASSIFICATIONS
CDCR 1951-8 (rev. 11/08)
Completion of this supplemental application is required of all nonpeace officer applicants seeking employment with the California Department of
Corrections and Rehabilitation (CDeR), as set forth in the Department of Corrections Operations Manual, Section 31060.17, 31060.18 and State of
California Labor Code Sedion 432.7. ThiS questionnaire wHisupplemenl the information provided on your application/resume and will tie considered
during the selection
Complete ALL items. If a question does not apply, enter "DNA." If appointed to any position within the COCR, you
will be
the purposes of obtaining a criminal record check from the Department
Justice,
LOCATION (INSTITUTION, DIVISION,
DATE
. DATE OF BfRTH
NAME (LAST, FIRST, MIDDLE)
A-D-D-'-R-E-S-S-:-~~--------;--I-CI-T-i---"----I'--ST"'CA'--:T"'CE-:--/'z=j=-p-
1--'-'
OTHER NAMES KNOWN BY (INCLUDING M,AfDEN)
SOCIAL SECURITY
PLACE OF BIRTH
NUM=-BE=R~-+-::Dc=R=JV=E=R='S:---U-:-C':::E=N"C:"SE==-'::--:c-:=---:-----------i
Have you ever been arrested for any violation of the law? List all arrests or citations and their disposition, regardless of when or where they
occurred. All arrests must belJsted, including those that you believe may have been deleted from your official records. You may only omit those
arrests that have that have been sealed, expunged,or destroyed pursuant to Penal Code Sections 851.7, 851.8, 1000.4, 1000.5 or 1203.45; or
pursuant to Health and Safety Code Seclion 11361.5; or pursuant to Welfare and Institutions Code Section 781. You may also omit Vehicle Code
infractions unless the position you are applying for requires that you operate a State-owned vehicle or your own or rental vehicle while on State
business. Failure to accurately list your arrests will be grounds to deny your application and/or terminate your employment
CHECK ONE:
PLACE AND DATE OF ARREST
CITYISTATE
1.
2.
II MONTH/YEAR
0
NO
:=J
----I
IF ADDITIONAL ROOM IS NEEDED)
I
I
I
YES (IF YES, LIST ALL OFFENSES BELOW. USE BACK OF FORM
SPECIFIC CHARGE
I
,
DISPOSITION
I
'3.
I
,
If confined for any of the offenses listed above, tomplete the
NO
PLACE OF CONFINEMENT
.
in relation to the numbered offense .
DATES
i
LENGTH
I
..
In accordance with the California Code of Regulations, Title 15, Crime Prevention and Corrections, Section 3411; If an employee is subsequently
arrested or convicted, the employee must promptly notify the institution head or.deputy/assistant director. Pursuant to Section 3406, If an employee
becomes aware thai any relative or close friend has been committed or transferred to the jurisdiction of CDCR, the employee muslrepor! the matter in
writing to the institution head or deputy/assistant director. Penal Code Section 4572 prohibits any person who has been previously convicted of a
felony flnd confined in any State prison in this Sate, fo come upon the grounds of any prison, forestry camp, or where any custodial inmates are
.
located, without the consent of the warden or other officer in charge of that facility.
I hereby certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and .thataH statements and answers are
true and correct. I understand and agree that If any material facts are discovered which differ from those facts stated by me on my employee
applicalion, this supplemental application, during my interview, or at any time prior to employment with COCR, r may not be offered the job.
Furthermore, I understand 'and agree that if material facts are later discovered Which are inconsistent with or differ from the facts I furnished before
dismissal from State service.
I
be disciplined,
to and
!
7
PHIMARY LAWS, RULES AND REGULATIONS REGARDING
CONDUCT AND ASSOCIATION WITH STATE PRISON INMATES
CDC 181 (Rev 5198)
Individuals who are not employees 0 1 the California Oepartmen: of Corrections and Rehabilitation (CDCR), but who are working In and around inmates
who are incarcerated within California's institutions/facilities or camps, are !o be apprised of the :aws, rules and regUlations governmg conduct as
associating with prison inmates. The following IS a summation of pertinent information when non-departmental employees come In contact with Drison
inmates.
Persons who are not employed by COCR, but are engaged in work at any institution/facility or camp must observe and abide by all laws, rules and
regulations governing the conduct of their behavior in associating with prison inmates. Failure to comply with these guidelines may lead to expUlsion from
COCR institutions/facilities or camps.
SOURCE:
Penal Code (PC) Sections 5054 and 5058; California Code of Regulations (CCR), Title 15, Sections 3285
and .3.415.
.
COCR does not recognize hostages for bargaining purposes. CDCR has a"NO HOSTAGE" policy and all prison inmates, visitors and employeesshall be
made aware of this.
.
.SOURCE: PC Sections 5054,5058; CCR, Title15, Section 3304
All persons entering onto institution/facilfty orcamp grounds consent to a search of their person, property or vehicle at any time, Refusal by Individuals to
submit to a search of their person, property or vehicle may be cause for denial or access to the premises.
SOURCE: PC Sections 2601, 5054 and5058;CCR, Title 15, Sections 3173, 317.7 and 3288
Persons normally permitted to enter an institution/facility or camp grounds consent to a.search of their person, property or vehicle at any fime. Refusal by
individuals t submit to a search of their person, property of vehicle may because for denial of access to the premises. .
.
SOURCE: PC Sections 5054 and 5058; CCR. Title 15, Section 3176 (aJ
It is illegal for an individual who has been previously convicted of a felony offense to enter into CDCR institutions/facilities or camps without the prior
approval of the Warden. It is also illegal for an individual to enter onto these premises for unauthorized purposes or to refuse to leave said premises when
requested to do so. Failure to comply with this provision could lead to prosecution.
SOURCE: PC Sections 602, 4570.5 and 4571; CCR, title 15, Sections 3173 and 3289
Encouraging and/or assisting prison inmates to escape, is a crime. It is illegal to bring firearms, deadly weapons, explosives, teargas drugs or drug
paraphernalia on CDCR institutions/facilities or camp premises. It is illegal to give prison inmates firearms, explosives, alcohol beverages, narcotics or any
drug or drug paraphernalia, including cocaine or marijuana.
SOdRCE: PC Sections 2772, 2790, 4533, 4535, 4550, 4573, 4573.5, 4573.6 and 4574
It is illegal to give or take letlersfrom prison inmates witHout the authorization of the Warden .. It is also iilegalto. give orreceive any type of gift and/or
gratuities from prison inmates.
SOURCE: PC Sections 2540,2541 and 4570, CCR, TiUe 15, Sections3010, 3399,3404,3424, and 3425
In an emergency situation the visiting program and other program activities may be suspended. SOURCE: PC Section 2601; CCR, Title 15, Section 3383 For security reasons, visitors must not wear clothing that in any way resembles state issued prison inmate clothing (blue den im shirts, blue denim pants). SOURCE: CCR, Title 15, Section 3171 (b) (3) Interviews with SPECIFIC INMATES are not permitted. 90nspiring with an inmate to circumvent policyand/or regulations constitutes a rule violation that may result in appropriate legal action SOURCE: CCR, Title 15, Section 3261.5, 3315 (3) (W), and 3177 I HEREB\, CER I IrY AND At.KNOW[tDGt I HAVE READ I Rt ABOVt AND FOLL YONDERS i AND I At: IMPLICA liONS REGARDlNG My GoNOUG I AND ASSo~IA I ION WII A PRISON INMATES. I ALSO UNDERSTAND VIOLATION OF ANY OF THE ABOVE COULD RESULT IN EXPULSION FROM A CDCR INSTITUTION/FACILITY OR CAMP WITH THE POSSIBILITY OF CRIMINAL PROSECUTION. i N: vnginal - .Assistant
irector, vommunicahoos
To be completed by Personnel
Date CII fingerprint mailed: _ _.___.___
Date CII record returned~to eMF: - _ .
Personnel action basetion Gil record:
( ) Card issued.
( ) Card not issued, eil record returned to Division Head for action.
( ) Card not issued. other reason - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _....,--_ __
To be comoleted bv Administrative Assist,mt or Community Resource Manager:
( ) CII record reviewed, approved for issuance.
) CII record reviewed, not approved for issuance.
AA or CRM
/
---Date
/
----
STATE OF CAlIF04NIA
OATH OF ALLEGIANCE AND DECLARATION OF PERMISSION TO WORK
FOR PERSONS EMPLOYED BY THE STATE OF CALIFORNIA
STD, GBS (REV. 9-90)
Oath may be administered by a person having general authority by law to administer oaths--or may be administered
by the appoinling po wer, or by a person for whom writ/en alllilorizalion to witness oaths has been executed by the
appointing power. The appointing power maintains a file of such Qlllilorizalions .
. WH9 MUST SIGN OATH --As required in Section 3 of Arlic1eXX of the ConstilUuon of California, every ,Stateemployee,e;.;cept
legaUy employed noncitizens, mustsign an oath or affirmation before heor she enters upon the duties of his or her State employment.
Noncitizens are required to possess a Declaration of Permission to Work. If an alien employee becomes a naturalized citizen, an oath
must then be obtained and filed.
"
WHEN OATH MUST BE SI GNED--As required in Government Code Section 31 02, all public employees and aJl volunteers in any
disaster councilor emergency organization accredited by the California Emergency Council must sign an oath or afftrmation before
entering upon the duties of their employment. For intermittent, temporary or emergency employments, an oath or affirmation may, at
the discretion oflhe employing agency, be effecti ve for all successi ve periods of employment which commence within one calendar year
from the date of the oath.
WHERE OATHS ARE FILED·-As required in Government Code Section 3105, all oaths for public employees and all volunteers in
any disaster councilor emergency organization accredited by the California Emergency Council, shall be filed in the official employee
file within 30 days of the dale the oath is executed. The oath is considered a public record.
FAILURE TO SIGN--As stated in Government Code Section 3107, no compensation or reimbursement for expenses incurred shall be
paid to any public employee or any I'oltm teer in any disaster councilor emergency organization accredited by the Califomia Emergency
Council unless such public employee has taken and subscribed to the oath or affirmation.
PENALTIES (Government Code)
"3108. Every person who, while taking and subscribing to the oath or affirmation required by this chapter, states as true any
material matter which he knows to be false, is guilty of perjury, and is punishable by imprisonment in the state prison not less
than one nore more than 14 years."
(Typ" Of pnnl name 01 errpioY""J
I,
,do solemnly swear (or afftrm) that I will support and defend
.the
of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will
bear !.fue faith and allegiance to the Constitution of the United States and theConstitutiOil of the State ofCalifbrnia; that I take this
obligation freely;without any mental reservation orpurposeof evasion; and that I will well andfailhfully discharge the duties upon which
I am about to enter.
PART 2··DECLARAT10N OF PERMISSION TO WORK
I am a lawful permanent resident alien of the United States.
YES
NO
If NO, please read the foJlowing:
I hereby certify, that I have permission to work in this country and have declared any restrictions placed upon me in this regard by
the Uniled States governmen tto the appointing power.
PAnT :l .. SIGi\' ",TURE "'C'iD CERT1FfCATION (No fee
EMPLOYEE'S SIGNATURE
Taken and subscribed before me this
mal' be charged [or adminiJ/erillgJ
NOTICE TO ALL CALIFORNIA DEPARTMENT OF CORRECTIONS
~MPLOYEES INCLUDiNG CONTRACT MEDiCAL STAFF
In 2002, The California Department of Corrections (COG) enferedinlo a settlement in the
case of Plata v. Schwarzenegger, the purpose of which is to improve medical care and
treatment of inmates at California prisons and ensure that such care and treatment meets
minimum constitutional standards.
forth in a Stipulation for Injunctive Relief (Stipulation) ..:....:...:...:.:.=...:..-:.:::........;::::!..:
The settlement is
order of the Court. This Order requires the CDC to implement the Inmate Medical Services
It ar'so.provides that
Program (lMSP) Policies and Procedures at this institution.
implementation of the IMSP will be monitored by(1) Medical Experts appointed by the Court,
and (2) lawyers representing the inmates.
. The CDC is fully committed to the complete implementation of the lMSP Policies and
Procedures at every institution. As such, it expects each and every employee of the CDC to
fully reflect this commitment by cooperating 100 percent with the implementation of the IMSP
Policies and Procedures, and the monitoring efforts conducted by both the Court appointed
Medical Experts and lawyers representing the inmates. There is Protective Order in place
that ensures that inmate medical information which must be provided to (or made accessible
to) the Court appointed Medica! Experts and the inmates' lawyers will remain confidential.
Thus court-sanctioned disclosure of this information to the Court appointed Medical Experts·
and the inmates' lawyers is not a vioiation of Privacy laws or the Health Insurance Portability
and Accountability Act (HIPAA).
a
The effective implementation of IMSP Policies and Procedures is of the highest priority for
the CDC. Thus, any person who intentionally fails to cooperate 100 percent with the
implem~ntation ,and monitoring efforts described above will be in violation of CDC policy and
subject to discipline. 'in addition, any person who intentionally fails to cooperate 100 percent
. with the implementation and monitoring efforts described above may be personally subject to
the jurisdiction of the United States District Court for the Northern District of
IifOrnia,
including. possible contempt or court proceedings, monetary fines, and/or incarcf:)ratiDn.
.
.
I acknowledge receipt of this notice and understand I am expected to cooperate with the implementation and monitorir _. ~fforts in Plata. Dated: - - - - - -
Employee Name
Employee Signature
Dated: - - - - - -
Supervisor/Employee Providing Notice
Distribution: Original-Personnel '-ile, Copy-Employee
\ b
I
ATTACHMENT
S
DEPARTMENT OF C'{.)RRECTI(}N
STATEOFCALIFI.}RNIA
EMPLOYEE TUBERCULIN SKIN TEST {TST} AND nVALUATION
CDC 7336(Rev. l0l0z)
DlsTRlBt:'rloirt:
WHITE : HCSDPUBLICHEALTHSE(.TION
: EMPLOYEE
MEDICALFII,,E
YEI-L,OW
CONITIDENTIAL EMPLOYEE MEDICAL TNFOR,MATIOI\
PINK
: EMPI,OYEE
INSTRUCSONS:Tuberculosis(TB) screeningmust be performedby a licensedhealth care provider whoselegalll
of practice allows himlher to conduct medical examinationsandior the Mantoux TB Skin Test(TST) in aceordancewith the
of the Centers for DiseaseControl ancl Prevention to determine if a per.sonhas TB infection
,"io**"ndations
or disease.
thefollowing sectiort - type or print dear[-v]
Comptete
EMPLOYEE {
' 1 ',
EMPI.,OYEE INFORMATION
GENDER
PRIN'I'ORTYPE EMPLOYEE'SITI'LL iqAiT/ T(AS I-TAPPEARSON .STATEI}AYCHECK}
LAST
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FIRST
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I]IRTHDATE
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DEP.qR1-MSNT
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DATE
EMPLOYEE SIGNANJRE
HEALTH CAfr.EPROVIDER (ContpteteSections2-6 ns required- refer to instructionson reversesideofform)
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S
PRIOR TB DISEASE?
PRTORSIGNIFICANTTB SKIN
TES'I'/INFECTION?
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INDURATION SIZE:-MM
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TSITADMINISTRATION (5TU/ 0.I milliliter)
$.
LOTNUMBER
{CHECK ONE}
n
n
INJECTION SITE:
TS'I'ADMINIS'ERED BY
(PRINT NAME}
SICNATLIRE:
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TST RESULT
tMtu{ INDURATIONI
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EVALUAfiON FOR SIGNSANDSYMPTOMS{MUST BE COMPLETSDFORALLINDIVIDUAI"S}
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DI.\TE:
EXPIRAI]ON DAI'E:
TUBERSoL
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I*l: EMPLOYEEpttOv:InBD,WRITTENNOTTFICATION
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NOTTCE
.
PLEASE READ PRIOR TO TESTING
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coNslSTENTwlrB
il employeeis Free of InfectiousTuberculosis
E\ALUATOR NAMI:
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DATE
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