SOP_NUMBER: 109.01-att-9 TITLE: GDC OPS Background Screening Packet REFERENCE_CODE: VF01-0001 DIVISION: Inmate Services TOPIC_AREA: 109 Policy-Volunteer Services EFFECTIVE_DATE: 2020-06-30 WORD_COUNT: 1936 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/629193 URL: https://gps.press/sop-data/109.01-att-9/ SUMMARY: This attachment provides the required background screening forms and procedures for all volunteer applicants to the Georgia Department of Corrections. Volunteers must complete a comprehensive background packet including a personal history questionnaire, authorization for release of personal information, and disclosure of any criminal history, financial records, employment history, and other relevant information. Failure to complete the forms or providing false or evasive information will result in disqualification from volunteering. KEY_TOPICS: volunteer application, background investigation, background screening, personal history questionnaire, release of information authorization, volunteer eligibility, volunteer vetting, criminal history disclosure, employment background check, financial records review, social media accounts ATTACHMENTS: 1. Volunteer Service Agreement URL: https://gps.press/sop-data/109.01-att-1/ 2. GDC Volunteer Application - Personal Data Sheet URL: https://gps.press/sop-data/109.01-att-2/ 3. Sample Request For Identification Card URL: https://gps.press/sop-data/109.01-att-3/ 4. Volunteer Services GCIC_NCIC Consent Form URL: https://gps.press/sop-data/109.01-att-4/ 5. Visiting Volunteer Waiver of Liability URL: https://gps.press/sop-data/109.01-att-5/ 6. Annual Volunteer Services Evaluation URL: https://gps.press/sop-data/109.01-att-6/ 7. Volunteer Application Processing Checklist URL: https://gps.press/sop-data/109.01-att-7/ 8. Volunteer ID Renewal Certification Validation Form URL: https://gps.press/sop-data/109.01-att-8/ 9. GDC OPS Background Screening Packet URL: https://gps.press/sop-data/109.01-att-9/ ======================================================================== FULL TEXT: ======================================================================== **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.