SOP 104.09-att-4: Applicant Verification Form

SOP 104.09
Attachment 4

5/25/22

GEORGIA DEPARTMENT OF CORRECTIONS Applicant Verification

Name:

Position#: Position Location:

Provided Essential Job Functions for Position Title:

At Interview:
_(completed by Applicant – Please carefully read and initial all applicable statements.)_

Essential Job Functions: I verify that I have read and understand all of the Essential Job Functions and Basic Training
functions, if applicable, related to the position indicated above. I further verify that I can perform the Essential Job Functions with
or without reasonable accommodation.

PREA Prohibitions: The Georgia Department of Corrections (GDC) must adhere to the United States Department of
Justice Final Rule on the “National Standards to Prevent, Detect, and Respond to Prison Rape Under the Prison Rape Elimination
Act (PREA) Standards” at 28 C.F.R. Part 115 Docket No. OAG-131. GDC may not hire or promote anyone who may have contact
with inmates, residents or offenders under supervision who answers “Yes” to any of the following questions:

1. Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or
other institution? Yes No
2. Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by
force, or coercion, or if the victim did not consent or was unable to consent or refuse? Yes No
3. Have you been civilly or administratively adjudicated to have engaged in the activities described? Yes No

I acknowledge and understand that should I become subject to the PREA prohibitions in my current position or any subsequent
departmental position I may hold, I will notify departmental management within twenty-four hours of my involvement in any of
the above. I understand the Department has the authority to conduct random criminal background checks to ensure compliance
with these federal standards in relation to the Department’s employment practices. Further, I understand that if I am subject to the
PREA Prohibitions and answer “yes” to any of the above questions, I may be subject to termination of employment. In addition,
if I falsely respond to the questions regarding PREA Prohibitions, I will be subject to termination or disqualification for
employment.

Signature: Date:

At Conditional Offer of Employment:

_(Completed by Applicant)_

I verify that I have read and understand all of the Essential Job Functions and Basic Training Functions, if applicable,
related to the position indicated above. I further verify that I can perform the Essential Functions (Check ONLY one
box) :
# □ with reasonable accommodation □ without accommodation

Signature Date

Retention Schedule: Upon completion, this form shall be retained permanently in the official and local personnel files if hired; For applicants not
hired, the form shall be retained for two (2) years in the local personnel office at the hiring facility, as part of the Selection Package.