DIVISION OF YOUTH CORRECTIONS Applicant Reference Checks Permission Record
I understand that as part of the Interview/Application process, this agency may need to verify personnel and time keeping information as well as contact references. My dated signature below provides this agency permission for them to contact the appropriate personnel to obtain reference checks, review my personnel file and time keeping records. Applicants Print Name:_____________________________________ Applicants Signature:________________________________________________ Date:________________ PLEASE ANSWER THE FOLLOWING QUESTIONS: 1. 2.
3.
Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution; Yes No Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse; or Yes No Have you been civilly or administratively adjudicated to have engaged in the activity mentioned above. Yes No
Your signature below acknowledges that you have not been charged with, arrested for, civilly or administratively adjudicated for any of the above offenses and you understand it is your duty to report any of the offenses mentioned. If you are offered a position with DYC material omissions regarding such conduct, or the provision of materially false information may be grounds for disciplinary action up to and including termination.
Applicants Print Name:_____________________________________ Applicants Signature:________________________________________________ Date:________________ •
Applicant shall provide past/present institution employers contact information on page 4 if applicable (Institution, Facility Director’s Name, Contact #). Page 1 of 4 October 2015
DIVISION OF YOUTH CORRECTIONS Applicant Reference Checks Record Applicant Name:___________________________________________________ Interview Date:__________________________ As part of the reference check process we are asking that you provide us with the following information ( Please complete sections 1, 2, and 3: 1) Last 2 Performance Ratings Rating: _____________________ Your comments:_________________________________________________ ____________________________________________________________________________________________________ To be completed by Facility/Region/Program/Office: Verified by: __________________________________ Position:__________________________________________________ Date: ________________________ by Whom:_______________________________________________________ Comments:________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Rating: _____________________ Your comments:_________________________________________________ ____________________________________________________________________________________________________ To be completed by Facility/Region/Program/Office: Verified by: __________________________________ Position:__________________________________________________ Date: ________________________ by Whom:_______________________________________________________ Comments:________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2) Please provide us with an estimate of your current Leave balances: Sick:___________ Annual:___________ Holiday:___________ Comp time:___________ Other:______________ To be completed by Facility/Region/Program/Office: Verified by: __________________________________ Position:__________________________________________________ Date: ________________________ by Whom:_______________________________________________________ Comments:________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3) If you have not listed your current and most previous Supervisors on your application, please provide their information below: Current Supervisor Name:_______________________________________________ Position:_______________________ Work Location:__________________________________________________ Contact #:_____________________ Previous Supervisor Name:______________________________________________ Position:_______________________ Page 2 of 4 October 2015
Work Location:__________________________________________________ Contact #:_____________________ To be completed by Facility/Region/Program/Office: Reference Names and Information Per Application / Verified by the Potential Employee Reference Name:______________________________________ Work Site:_________________________________________ Position/Relationship:______________________________________________ Contact #:___________________________ Reference checked date/time: ______________________________________________________________________________ Checked by Name:_______________________________________________ Comments: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
Reference Name:______________________________________ Work Site:_________________________________________ Position/Relationship:______________________________________________ Contact #:___________________________ Reference checked date/time: ______________________________________________________________________________ Checked by Name:_______________________________________________ Comments: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
Reference Name:______________________________________ Work Site:_________________________________________ Position/Relationship:______________________________________________ Contact #:___________________________ Reference checked date/time: ______________________________________________________________________________ Checked by Name:_______________________________________________ Comments: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Page 3 of 4 October 2015
To be completed by Facility Hiring Manager: Question: Did (potential employees full name) have any substantiated allegations of sexual abuse or a resignation during a pending investigation of an allegation of sexual abuse while employed at your institution? Reference Name and Information for any Federal, State, and local prison, jail, lockup, community confinement facility, or juvenile facility both private and government. Institution:_________________________________________ Facility Directors Name:______________________________________ Contact #:___________________________ Reference checked date/time: ______________________________________________________________________________ Checked by Name:_______________________________________________ Comments: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Institution:_________________________________________ Facility Directors Name:______________________________________ Contact #:___________________________ Reference checked date/time: ______________________________________________________________________________ Checked by Name:_______________________________________________ Comments: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Institution:_________________________________________ Facility Directors Name:______________________________________ Contact #:___________________________ Reference checked date/time: ______________________________________________________________________________ Checked by Name:_______________________________________________ Comments: __________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Page 4 of 4 October 2015
