EFTA00035605

BP-80203 FEDERAL PRISON SYSTEM PRETRIAL INMATE WORK C:Drati JUN 10 WAIVER/NOTICE OF SEPARATION DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS U.S. I. INSTRUCTIONS depending upon the design, The staff member conducting intake screening shall advise the pretrial inmate, with convicted structure, and operation of the individual institution, that the inmate may have contact II of this Pretrial Inmate inmates. The inmate is to be asked to sign the appropriate portion in Section of the form, staff shall Work Waiver/Notice of Separation. If the inmate refuses to sign this segment document this refusal on the form. e portion in A pretrial inmate who wishes to waive the exemption from work must sign the appropriat be completed prior Section IV of this Pretrial Inmate Work Waiver/Notice of Separation. This form must d the to the issuance of a work assignment. If the inmate's behavior suggests an inability to comprehen the waiver, or if the inmate has been admitted to a mental health referral for evaluation or treatment, the inmate must be referred to a mental health professional for an assessment as to competency to sign waiver. The waiver may be rescinded at the inmate's request and reasons for the rescission should be in the documented in Section V of this form and signed by a staff member. The waiver shall be maintained inmate may inmate's unit file or record office file and will remain in the file as a permanent document. The be given a copy of this form if the inmate so requests. II. NOTICE OF SEPARATION A. I unde d that it is possible that I will have contact with inmates already convicted of a crime. I (circle one) aware of any reason why my having contact with convicted prisoners w ul pose a thre my safety or the safety of others. B ex031%-osi 72,41 to Signature Reg. No. Date Staff Signature/Tide B. Inmate Refuses to Sign Date Staff Signature/Title REASONS STATED (IF ANY ): EFTA00035605 III. POLICY work other than to perform Bureau of Prisons policy states a pretrial inmate may not be compelled to housekeeping tasks in the inmate's own cell and in the community living area. FOR STAFF USE ONLY I am referring this inmate to the institution's psychologist/psychiatrist because: waiver. The inmate's behavior suggests the inmate may not be able to comprehend this The inmate has been admitted for mental evaluation or treatment. Staff Signature /Printed Name /Title Date rv. WORK WAIVER I l,e a l c had read to me the policy provisions in Section II of this form and would like to volunteer for a work assignment which entails more than housekeeping tasks. I understand that as a person not convicted of a crime I may not be required to work. rIG3it-aq 7%4 ? p Inmate Signature Reg. No. Date Staff Signature/Title V. REVOCATION OF WAIVER I hereby rescind the work waiver previously claimed above: Inmate Signature Reg. No. Date Staff Signature/Title STAFF COMMENTS: WDP Pfeeesibed by P7331 Replaces BP-203(73) OP APR 80 and BP-5203(73) of May 94 2 EFTA00035606