SOP 109.01-att-9: GDC OPS Background Screening Packet

GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_

_State Offices South at Tift College_

_P. O. Box 1529_
_Forsyth, Georgia 31029_

~~SOP 109.01~~
Attachment 9

6/30/20
Page 1 of 9

Timothy C. Ward

_Commissioner_

Brian P. Kemp
_Governor_

Dear Applicant,

Thank you for your interest in volunteering with the Georgia Department of Corrections. All
volunteers are now required to successfully complete a background investigation. As part of the
application process you will be required to complete and submit the information requested herein.
Enclosed you will find the Background Packet consisting of a Questionnaire and Authorization for
Release of Personal Information, along with instructions for each. Please complete and submit along
with the volunteer application. Any applicant, who fails to complete the required forms and to
supply proper documents will be removed from further consideration.

It is vitally important that you provide full and complete information. Any evasion, omission or
deliberate false statement by you will invalidate your application.

Sincerely,

Clay Nix

Clay Nix
Director of Office of Professional Standards
Georgia Department of Corrections

_Equal Opportunity Employer_

SOP 109.01
Attachment 9

6/30/20
Page 2 of 9
GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_ Background Screening Packet

- _Incomplete forms/packets will not be accepted._

- You must answer all questions correctly. Do not use “N/A”, meaning not applicable. _Failure to_
_furnish the pertinent information requested on the application may result in the Office of_
_Professional Standards being unable to complete a background investigation and may disqualify_
_you as a candidate for volunteering. Intentional omissions or false answers will be a basis for the_
_termination of the application process._

- If you are unable to provide any of the information requested, an explanation must be given as to
the reason.

- _The information provided by you will be subject to a background investigation._

- Questions concerning your background packet may be directed to Volunteer Services at 478-9926406 or Chaplaincy Operations _at 478–992–5908._

- Any information received throughout the review process including, but not limited to, the

background packet, release forms, employment information, psychological reports, credit
information, medical information, etc., are the sole property of GDC and no information will be
released back to the applicant.

- Please read the following statements, then sign and date this form. Your signature denotes that

you have read and understand the statement:

1) I UNDERSTAND THAT IF I DO NOT WISH TO ANSWER A QUESTION IN THIS

BOOKLET, I MAY CHOOSENOT TO DO SO AND MY APPLICATION WILL BE
TERMINATED.

2) I UNDERSTAND THAT IN ORDER TO PROMOTE AND ENCOURAGE CANDID

EVALUATIONS BYPERSONS INTERVIEWED DURING APPLICANT
BACKGROUND INVESTIGATIONS, ALL EVALUATIONSSHALL BE
CONFIDENTIAL, PURSUANT TO THE OPEN RECORDS ACT. CONFIDENTIAL
EVALUATIONS ARE INFORMATION OR RECORDS WHICH ASSESS WORK
PERFORMANCE, PREJUDICES, INTEGRITY, ETHICAL CONDUCT, HONESTY,
FINANCIAL RESPONSIBILITY, OR PAST PERSONAL BEHAVIOR.

_________________________________ _____________________
_Signature Date_

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 3 of 9
GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_ Background Screening Packet _AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION_

I do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized agent of
the Office of Professional Standards, whether such records are of a public, private, or confidential nature.

The intent of this authorization is to give my ongoing consent for full and complete disclosure of all records of my
driver’s history, criminal history, educational background, military personnel records, records of military service,
records of financial or credit institutions (including records of loans), records of commercial or retail credit agencies
(including credit reports and/or rating), records of the Georgia Department of Revenue, and any other financial
statements and records wherever filed; medical and psychiatric treatment and/or consultation, including hospitals,
clinics, private practitioners, and the U.S. Veterans Administration; employment and pre-employment records
(including background reports, polygraph reports and charts, efficiency ratings, complaints or grievances filed by
or against me), and records of local, state, and federal criminal justice agencies.

_I understand that any information obtained by a personal history background investigation, which is developed_
_directly or indirectly, in whole or in part, upon this release authorization, will be used in determining my suitability_
_and continuing suitability for volunteering._ I authorize the disclosure of the aforementioned personal information
to any person(s) deemed by the Office of Professional Standards within the Georgia Department of Corrections to
be a participant in the determination process of volunteer suitability. I also certify that any person(s) who may
furnish such information concerning me shall not be held accountable for giving this information; and I do hereby
release said person(s) from any and all liability which may be incurred as a result of furnishing such information.

A photocopy of this release form will be as valid as the original form, even though the photocopy does not contain
my original signature.

I have read and fully understand the contents of this Authorization for Release of Personal Information
Document.

Last Name First Name Signature

Street Address Date

City Sex Race

State Zip Date of Birth / Driver License # / State

Social Security Number

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 4 of 9
GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_ Background Screening Packet _PERSONAL HISTORY_

DATE: FACILITY IN WHICH YOU WILL BE VOLUNTEERING:

Name:
Last Name First Name Middle Name

LIST ANY OTHER NAMES YOU HAVE USED OR BEEN KNOWN BY & WHY: (IF NONE, SO STATE:)

DATE OF BIRTH: PLACE OF BIRTH:
Month/Day/Year City/State

SOCIAL SECURITY NUMBER:

MARITAL STATUS: AGE: SEX: RACE:

HEIGHT (ft/in): WEIGHT (lbs.): HAIR: EYES:

HOME ADDRESS:
Street Address

~~City~~ ~~State~~ ~~Zip~~ ~~County~~

HOME PHONE: WORK PHONE:

CELL PHONE: _____________________ Email address: _______________________________

PLEASE LIST ANY OTHER CELL PHONE OR EMAIL ADDRESS IN WHICH YOU ARE ASSOCIATED:

YOUR OCCUPATION:

BUSINESS NAME:

BUSINESS ADDRESS:

LIST ANY SOCIAL MEDIA ACCOUNTS THAT YOU POSSESS:

FACEBOOK: Yes No USERNAME: ___________________________________

INSTAGRAM: Yes No USERNAME: ___________________________________

TWIITTER: Yes No USERNAME: ___________________________________

OTHER: ___________________________ USERNAME: ___________________________________

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 5 of 9
GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_ Background Screening Packet _PERSONAL HISTORY_

List addresses of all residences for the last FIVE (5) years, starting with present.

From To Address City State
Month / Year Month / Year/ (Present)

/

/

/

/

# _CRIMINAL HISTORY_

Have you ever been arrested or been the subject of a criminal complaint or indictment or been required to appear
as a suspect or defendant in any criminal proceeding?
Yes No

Have you ever been a member of a Street Gang?
Yes No

To your knowledge, are any of your friends, associates or family
Street Gang members? Yes No

# _CONTRABAND/PERSONAL DEALINGS/SEXUAL CONTACT_

CONTRABAND: ANY ITEM NOT ISSUED BY THE DEPARTMENT OF
CORRECTION (CELL PHONES, TOBACCO, DRUGS, FINANCIAL
TRANSACTION CARD NUMBERS, ETC.)

PERSONAL DEALINGS: ANY CONTACT WITH A PERSON IN CUSTODY OR ON
PROBATION/PAROLE WHICH IS NOT IN CONJUNCTION
WITH YOUR OFFICIAL DUTIES

SEXUAL CONTACT: ANY TYPE OF SEXUAL CONTACT WITH A PERSON IN CUSTODY

OR ON PROBATION/PAROLE (KISSING, FONDLING, GROPING,
INTERCOURSE, ORAL SEX, ANAL SEX, ETC.)

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 6 of 9
GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_ Background Screening Packet

Have you ever intentionally introduced contraband into a
correctional facility?

Have you ever been accused of introducing contraband into a
correctional facility?

_If yes, when was the last time? _______________________________

Have you ever accepted any form of payment or gift from anyone
related to contraband and/or personal dealings with offenders?

Have you ever given contraband to an offender?

Have you ever had any type of sexual contact with an offender?

Yes No

Yes No

Yes No

Yes No

Yes No

Have you ever been accused of any type of sexual contact with an Yes No
offender? _If yes, when was the last time?_ __________________________

Do you have any relatives/ friends or associates that are incarcerated? Yes No

_If you answered “yes” to any of the above questions, an explanation is required:_

# _SECURITY_

Have you ever been a member of any group or organization that advocates
violent dissent or the overthrow of this government or any other government?

Have you ever been a member of a group or organization that advocates
violence, racism, or other illegal activities?

Have you ever been involved in any type of riot, illegal demonstration or illegal
strike?

Yes No

Yes No

Yes No

Have you ever participated in the use or manufacture of
explosive devices or firebombs??

Yes No

_If you answered “yes” to any of the above questions, an explanation is required:_

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 7 of 9
# GEORGIA DEPARTMENT OF CORRECTIONS _Office of Professional Standards_ Background Screening Packet _DRUG HISTORY_

Are you currently using any illegal drugs? Yes No

_If yes, list type of drug(s) used, amount used and how often used:_

_Type of Drug_ ~~_Amount Used_~~ ~~_COMMENT_~~

_Type of Drug_ ~~_Amount Used_~~ _COMMENT_

To your knowledge, do any of your
illegal drugs?

Friends or associates use Yes No

_If you answered “yes” to any of the above questions, an explanation is required:_
____________________________________________________________________________________
____________________________________________________________________________________

# _WORK/VOLUNTEER HISTORY_

List ALL activities you have participated in the past 5 years. _Put your PRESENT or MOST RECENT_
_ACTIVITY FIRST._ Include Military Service in proper time sequence. List temporary or part-time jobs
REGARDLESS OF HOW LITTLE TIME WAS INVOLVED. If you need more space, you may attach
additional pages.

From _________________________ To___________________ Title_____________________________

Name of Organization _____________________________________________________________________

_______________________________________________________________________________________
Street Address City State Zip Code

Phone Number ______________________________ Full-Time Part-time

Work / Volunteer Activities:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 8 of 9
GEORGIA DEPARTMENT OF CORRECTIONS
# _Office of Professional Standards_ Background Screening Packet

From_________________________ To___________________ Title _____________________________

Name of Organization_____________________________________________________________________

_______________________________________________________________________________________
Street Address City State Zip Code

Phone Number ______________________________ Full-Time Part-time

Work / Volunteer Activities:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

From_________________________ To___________________ Title _____________________________

Name of Organization_____________________________________________________________________

_______________________________________________________________________________________
Street Address City State Zip Code

Phone Number ______________________________ Full-Time Part-time

Work / Volunteer Activities:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

From_________________________ To___________________ Title _____________________________

Name of Organization_____________________________________________________________________

_______________________________________________________________________________________
Street Address City State Zip Code

Phone Number ______________________________ Full-Time Part-time

Work / Volunteer Activities:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.

SOP 109.01
Attachment 9

6/30/20
Page 9 of 9
# GEORGIA DEPARTMENT OF CORRECTIONS _Office of Professional Standards_ Background Screening Packet CERTIFICATION THAT MY ANSWERS ARE TRUE

I have read and understand each question on this questionnaire. My responses on this questionnaire are

true, complete and correct to the best of my knowledge and are made in good faith. I understand that

making a knowing and willful false statement on this questionnaire is a crime. I further understand that

making a false or misleading statement or failing to answer a question(s) will result in my disqualification

from consideration for volunteering with the Georgia Department of Corrections. I do hereby authorize

the Georgia Department of Corrections to conduct a review of all records concerning myself, whether

such records are of a public, private or confidential nature.

Full Name Printed: _______________________________________________________________________

Signature:_________________________________________________ Date: _______________________

Retention Schedule: Upon completion, this form shall become part of the volunteer’s file to be maintained for two (2) years
past termination of the volunteer’s services.