Georgia Department of Corrections Employee Hiring

Transcription

Georgia Department of Corrections
Employee Hiring Package
Please fill out the following information. It will be printed in each field on all the forms
that follow this document in this packet. If you need additional forms that are not in this
packet, you will need to fill them out individually.
Field Name/Description Applicant/Employee Data
First Name Middle Name Maiden Name Last Name Home Address Home Apartment Number Home City Home State Home Zip Code County of Residence Home Phone Work Phone Social Security Number Date of Birth Month: Place of Birth Employee ID (If Applicable) Race Gender Height Feet: Weight Eye Color Hair Color Job Title Day: Inches: Initial: Year: V.
SPECIALIZED MEDICAL GUIDELINES
MEDICAL AND PHYSICAL EXAMINATION PROGRAM (MAPEP)
Candidates for "Category 5" (security) positions must meet the requirements set forth in the General Medical
Guidelines plus the following specific physical standards.
A.
General:
Height and weight should not be such as to interfere with specific job activities.
B.
Vision:
1)
Distant Vision - Minimum vision of 20/40 in both eyes, corrected or uncorrected,
with or without glasses or contact lenses;
Near Vision - Minimum of 20/40 corrected or uncorrected in each eye;
Adequate Depth Perception and the Ability to Distinguish Color;
Peripheral Vision of at least 70 degrees in each eye.
2)
3)
4)
C.
Hearing:
Hearing loss no greater than 24dB (decibels) for the average of frequencies 500 Hz, 1000
Hz, 2000 Hz, and 3000 Hz in the better ear, unaided (without a hearing aid) or aided (with a
hearing aid).
“Normal hearing” is a hearing loss no greater than 24 dB at 250 Hz, 500 Hz, 1000 Hz, 2000
Hz, 3000 Hz, 4000 Hz, 6000 Hz and 8000 Hz in both the right and left ears, unaided.
D.
ENT:
Page 1 of 2

An Otoscopic examination is required prior to the air conduction audiogram.

A complete pure tone or warble tone air conduction audiogram is required and results
recorded for all candidates. The audiogram must be completed at all frequencies listed
on Form PAMS PH4 on both the right and left ears. The pure tone air conduction
audiogram is to be used as the baseline audiogram.

If the testing indicates air conduction thresholds to be within the stated hearing
guidelines for employment, no further hearing testing is necessary. However, if any
single air conduction threshold is obtained outside the normal, 0-24 dB range; i.e., if
hearing is not within “normal limits,’ the results of the test are explained to the
candidate and the recommendation is made to obtain a complete audiological
evaluation at the individual’s expense for his/her own hearing healthcare benefit.

If the testing indicates air conduction thresholds to be outside the stated hearing
guidelines for employment, the results of the test are explained to the candidate and
a complete audiological evaluation is recommended, it the individual’s expense for
his/her own hearing healthcare benefit.

In addition to the pure tone air conduction testing, warble sound field testing is
required and results must be recorded for all candidates who wear a hearing aid and
do not meet the guidelines on the air conduction test, to verify if an individual meets
the guideline for employment with the use of a hearing aid. If the site does not have
the personnel or equipment to satisfy this requirement, then a referral is indicated.

A qualified individual should administer the audiometric testing and perform the
otoscopic examination.
Qualified individuals include licensed audiologists,
otolaryngologists, physicians trained in hearing conservation, technicians who are
certified by the Council for Accreditation of Occupational Hearing Conservation, or
technicians trained by such a physician. A technician who performs audiometric tests
must be responsible to an audiologist, otolaryngologist, or physician.

All tests should be performed in an acoustic environment to meet the current ANSI
standards.

All audiometric equipment should be calibrated annually to meet current ANSI
standards.
There should be adequately free nasal breathing. The mouth should be free from
deformities or conditions that interfere significantly with distinct speech.
DO NOT SUBMIT THIS PAGE
FOR INFORMATION ONLY
V.
SPECIALIZED MEDICAL GUIDELINES
MEDICAL AND PHYSICAL EXAMINATION PROGRAM (MAPEP)
E.
Cardiovascular:
Rheumatic and congenital heart disease should be thoroughly evaluated by the
examining physician and commented on in the examination report. Atherosclerotic
(arteriosclerotic) heart disease, myocardial infarction, coronary insufficiency, angina
pectoris, and hypertension above 140/90 must be evaluated on an individual basis
and must not be of sufficient severity to interfere with the performance of all duties.
F.
Respiratory:
Free of infections, diseases or other pulmonary processes that would interfere with
the physical demands of the position.
G.
Gastrointestinal:
Must be free of any major pathological conditions that will interfere with the physical
requirements of the job.
H.
Rectum and Anus:
Major hemorrhoidal conditions and symptomatic pilonidal cysts must not be of
sufficient severity to interfere with the job.
I.
Hernia:
Hernia (E) which might interfere with the performance of duty would require surgical
repair with clearance from operating surgeon, prior to employment.
J.
Genital/Urinary:
Large varicocele or hydrocele, which might interfere with the performance of duties,
should be repaired with clearance from operating surgeon, prior to employment.
K.
Back and Neck:
History of significant injury, deformity, surgical procedures, or other spinal pathology
should be thoroughly evaluated by the examining physician and commented on in
the examination report.
L.
Extremities:
*If a prosthesis or orthosis is used, such prosthesis or orthosis must not
interfere with the performance of duty.
1) Upper Extremities - Both hands must have at least the index, middle, and one
other finger and must not interfere with the performance of duty; both thumbs
must be functional; or see (*) above.
2) Lower Extremities - Both lower extremities must be free from limitation of any
joint motion which would interfere with the performance of duties; both great toes
must be functionally normal; or see (*) above.
M.
Nervous System:
Central and peripheral nervous system disorders must be evaluated by the
examining physician. Applicants with seizures must be thoroughly evaluated by the
examining physician and all findings included in the examination report. Special
attention must be given to any history of seizure activity.
N.
Emotional Stability:
Any history of significant emotional instability or mental illness should be thoroughly
evaluated by the examining physician and commented on in the examination report.
O.
Laboratory Analysis: Tuberculin Skin Test is required. If there is a positive reaction of 10mm or greater, a
chest x-ray is required to document the absence of tuberculosis.
Items 1 through 4 are not required unless medical history or physical examination
results indicate that such tests are needed to adequately assess the applicant's
physical status.
1) Urinalysis (Multi-Test Stick): Abnormalities in the sugar and albumin tests must
be evaluated further. If Glycosuria is significant, must have Glucose Tolerance
Test and if albuminuria, must have the cause identified.
2) Hemoglobin or Hematocrit.
3) Chest X-ray.
4) Resting Electrocardiogram.
Page 2 of 2
MEDICAL AND PHYSICAL EXAMINATION PROGRAM
FOR CORRECTIONAL OFFICERS
NOTE: This physical must be performed by a Medical Doctor (MD) or Doctor of Osteopathy (DO); this physical
will not be accepted if performed by a Family Nurse Practitioner (FNP) or a Physician's Assistant (PA).
DESCRIPTION OF WHAT A CORRECTIONAL OFFICER IS REQUIRED TO DO:
Position requires employee to supervise and maintain control and custody of offenders at correctional facilities and work sites;
observe and monitor offenders for improper conduct and escape attempts; use physical force to restrain offenders; respond
quickly to emergency situations (e.g., escapes, riots); utilize and operate security and/or manual labor work detail equipment
(including motor vehicles in some classes); stand for extended periods of time; and engage in correctional officer training of a
physical nature. (See page 4 describing physical capabilities for training.)
NAME:
Social Security Number:
*******************************************************************************************************************************************
NOTE: See the attached medical guideline should you need clarification in the physical requirements for a correctional officer.
WEIGHT:
HEIGHT:
PULSE:
BLOOD PRESSURE: Systolic/Diastolic: _______________________________
(two additional readings if elevated) 1.) _______________________ 2.)
TUBERCULIN SKIN TEST (Test must be read between 24 and 72 hours of time given)
Date Given: ____________________
Date Read: _______________
Results: ________________
If the results are positive, chest X-Ray is required. Attach copy of Radiology report.
If the results are positive, have you taken the INH medicine? YES_______NO_______
OTOSCOPIC EXAMINATION:
RIGHT EAR ____________
LEFT EAR __________
PURE TONE AIR CONDUCTION TEST RESULTS: (This section is to be used for all pre-employment air conduction hearing testing.)
Right Ear
250
500
1000
2000
3000
Left Ear
4000
6000
8000
250
500
1000
2000
3000
4000
6000
8000
SOUND FIELD PURE TONE/WARBLE TONE TEST RESULTS: (This section is to be used in conjunction with the pure tone air conduction testing
section for all individuals with hearing aids who do not meet the guidelines on the air conduction test.)
250
500
1000
2000
3000
4000
6000
8000
Sound Field Test
If individual meets the stated hearing guideline, no further hearing testing is necessary for the purpose of employment. However, if any single air
conduction threshold is obtained outside the normal, 0-24dB range, the results of the test must be explained to the canditate and the
recommendation made to obtain a complete audiological evaluation at the individual’s expense.
Audiometer Serial Number ______________________________
Meets Hearing Guidelines
Yes
Date of Calibration _________________________
No
I certify that I am qualified to administer the audiometric testing and perform the otoscopic examination. (Qualified individuals include
licensed audiologists, otolaryngologists, physicians trained in hearing conservation, technicians who are certified by the Council for
Accreditation of Occupational Hearing Conservation, or technicians trained by such a physician. A technician who performs audiometric
tests must be responsible to an audiologist, otolaryngologist, or physician.) I certify the test was performed in an acoustic environment that
meets current ANSI standards.
Name
Signature
Page 1 of 3
Telephone Number
Date
PO/CO, Page 1 for COs
FOR SURVEILLANCE AND PROBATION OFFICERS
NOTE: This physical must be performed by a Medical Doctor (MD) or Doctor of Osteopathy (DO); this physical
will not be accepted if performed by a Family Nurse Practitioner (FNP) or a Physician's Assistant (PA).
DESCRIPTION OF WHAT A SURVEILLANCE OR PROBATION OFFICER IS REQUIRED TO DO:
Position requires employee to supervise and maintain control of offenders in their homes, the community, and work sites; observe
and monitor offenders for improper conduct; use physical force to restrain and subdue offenders; respond quickly to emergency
situations; utilize and operate motor vehicles; remain attentive and alert; and engage in officer training of a physical nature. (See
page 4 describing physical capabilities for training.)
NAME:
*******************************************************************************************************************************************
NOTE: See the attached medical guideline should you need clarification in the ph ysical requirements for a surveillance or probation
officer.
WEIGHT:
HEIGHT:
PULSE:
BLOOD PRESSURE: Systolic/Diastolic: _______________________________
(two additional readings if elevated) 1.) _______________________ 2.)
TUBERCULIN SKIN TEST (Test must be read between 24 and 72 hours of time given)
Date Given: ____________________
Date Read: _______________
Results: ________________
If the results are positive, chest X-Ray is required. Attach copy of Radiology report.
If the results are positive, have you taken the INH medicine? YES_______NO_______
OTOSCOPIC EXAMINATION:
RIGHT EAR ____________
LEFT EAR __________
PURE TONE AIR CONDUCTION TEST RESULTS: (This section is to be used for all pre-employment air conduction hearing testing.)
Right Ear
250
500
1000
2000
3000
Left Ear
4000
6000
8000
250
500
1000
2000
3000
4000
6000
8000
SOUND FIELD PURE TONE/WARBLE TONE TEST RESULTS: (This section is to be used in conjunction with the pure tone air conduction testing
section for all individuals with hearing aids who do not meet the guidelines on the air conduction test.)
250
500
1000
2000
3000
4000
6000
8000
Sound Field Test
If individual meets the stated hearing guideline, no further hearing testing is necessary for the purpose of employment. However, if any single air
conduction threshold is obtained outside the normal, 0-24dB range, the results of the test must be explained to the canditate and the
recommendation made to obtain a complete audiological evaluation at the individual’s expense.
Audiometer Serial Number ______________________________
Meets Hearing Guidelines
Yes
Date of Calibration _________________________
No
I certify that I am qualified to administer the audiometric testing and perform the otoscopic examination. (Qualified individuals include
licensed audiologists, otolaryngologists, physicians trained in hearing conservation, technicians who are certified by the Council for
Accreditation of Occupational Hearing Conservation, or technicians trained by such a physician. A technician who performs audiometric
tests must be responsible to an audiologist, otolaryngologist, or physician.) I certify the test was performed in an acoustic environment that
meets current ANSI standards.
Name
Signature
Page 1 of 3
Telephone Number
Date
PO/CO. Page 1 for POs & SOs
EYES:
DISTANT VISION:
Minimum of 20/40 corrected or uncorrected in each eye, with or without glasses or contact lens.
NEAR VISION:
Minimum of 20/40 corrected or uncorrected in each eye, with or without glasses or contact lens.
PERIPHERAL:
At least 70 degrees in each eye.
COLOR:
Able to distinguish color in both eyes.
DEPTH PERCEPTION:
Must be adequate in both eyes.
RIGHT EYE
PERIPHERAL AT LEAST
70 DEGREES
LEFT EYE
Uncorrected Distant 20/___
Uncorrected Distant 20/___
Corrected Distant
Corrected Distant
20/___
20/___
Uncorrected Near 20/___
Uncorrected Near 20/___
Corrected Near
Corrected Near
20/___
20/___
ABLE TO DISTINGUISH
COLORS
ADEQUATE DEPTH
PERCEPTION
Right Eye
Right Eye
Right Eye
____Yes ___No
____Yes ___No
____Yes ___No
Left Eye
Left Eye
Left Eye
____Yes ___No
____Yes ___No
____Yes ___No
PHYSICAL EXAMINATION
Clinical Evaluation
1.
Head, face, neck and scalp
2.
Nose
3.
Mouth and throat
4.
Ears
5.
Eyes
6.
Ophthalmoscopic
7.
Ocular motility
8.
Lungs and chest (breast if indicated)
9.
Heart
10.
Vascular system (Varicosities, etc.)
11.
Abdomen
12.
Anus and rectum (if indicated)
13.
Endocrine system
14.
Hernia (any type)
15.
Upper extremities
16.
Feet
17.
Lower extremities
18.
Spine
19.
Identifying body marks, scars
20.
Skin, lymphatics
21.
Neurological
22.
Mental status
Page 2 of 3
Normal
Abnormal
Remarks
PO/CO, Page 2
Allergies
1.
3.
2.
4.
Surgery
Type of Surgery
Date (Mo/Yr)
1.
2.
3.
4.
Comments/Implications for Fitness for Duty (Use back of this page if necessary).
Explain in detail any abnormality noted in history or physical examination. Discuss medical implications for job duty
assignment, if any.
NOTE: This physical must be performed by a Medical Doctor (MD) or Doctor of Osteopathy (DO); this physical will not be accepted if
performed by a Family Nurse Practitioner (FNP) or a Physician's Assistant (PA).
PHYSICIAN'S NAME:
Telephone Number:
Print
ADDRESS:
SIGNATURE:
DATE:
FOR CENTRAL OFFICE USE ONLY
Central Office Physician's Signature:
Page 3 of 3
PO/CO, Page 3
PRESENT T O PHYSICIAN AS PAGE 4 OF PHYSICAL
SUPPLEMENT AL ACKNOWLEDGEMENT
PHYSICAL CAPABILITY REQ UIREMENTS FO R GDC EMPLO YEES ATTENDING BCO T/BPO T
A number of positions within the Department of Corrections are designated as peace officers. Peace officers must attend
and successfully complete mandated training known as Basic Correctional Officer T raining (BCOT ) or Basic Probation
Officer T raining (BPOT ). T his training will require the physical activities indicated below.
, understand that my physician must review these physical activities and
I,
indicate approval of my participation in the training. I understand that, upon accepting this position, I am agreeing to
attend BCOT /BPOT although the Medical Reviewing Officer of the Department may not have reviewed my physical
prior to my attendance at training. I understand that if I cannot meet the requirements to attend training, I may not be
employed in a peace officer position.
1. Physical Fitness Assessment
Students will participate in two physical fitness assessments, one at the beginning and one at the end of the four week
training program, that require the student to perform as many push-ups and sit-ups as they can, each within one minute.
T he student will also participate in a one mile walk/run that measures the time it takes to complete one mile.
2. Fire Safety T raining
Donning a breathing apparatus weighing approximately 30 lbs. (Note: Student must be able to obtain a tight seal around
the entire face to avoid breathing toxic smoke.) Holding and using a fire extinguisher weighing approximately 20-25
pounds in a fire exercise. Student must be able to move extinguisher in sweeping motion from side to side while
holding. Fire extinguishers used are filled with siliconized sodium bicarbonate powder. T his is a nontoxic agent.
3. Defensive T actics T raining
Participating in 4 days of physical defense training, which includes bending, twisting, squatting, pulling, striking, and
kicking, etc., as well as demonstrating how to subdue a simulated volatile inmate/probationer. Kicking requires student
to lift one foot off the floor and deliver a strike. Punching techniques require both strength and dexterity. Falling down
during practice sessions is not uncommon. Demonstrating the ability to use the techniques taught to defend self or
others.
4. Inspections and Search T raining
Conducting a frisk/clothing search on another student, which requires bending and kneeling. Conducting a room search,
which requires bending, stooping and moderate stretching in order to see into inaccessible places.
4. Emergency Response T raining
T o train to recognize an emergency and how to respond appropriately. T his block of instruction includes a practical
exam in CPR and AED use. T his block of instruction will involve some physical activity, i.e. kneeling over body to
render aide.
5. Firearms T raining
Students are required to achieve qualifying scores on the range. Instruction will also be given regarding use of deadly
force. T his block of instruction will involve some physical activity, i.e. standing and kneeling on concrete with a loaded
weapon on the firing line while qualifying in inclement weather conditions. Possible inhalation of lead based smoke on
an outdoor range and exposure to cleaning solvents.
6. Standing/Marching Requirements
Students must be able to stand in formation and march to and from class in a uniform manner. Students may be required
to stand in formation up to fifteen minutes at a time.
I am aware of these physical requirements and have no limitations to prevent me from attending. I, therefore, assume all
liability for health risks/issues that may arise as a result of this training.
Date
Employee Signature
PO/CO, Page 4
Georgia Peace Officer Standards & Training Council
Corrections/Probation Officer Application for Certification
Pg __
Of __
Initial
____
Physician’s Affidavit – PAGE 1 of 3
PHYSICIAN’S INSTRUCTIONS:
Please complete this form and answer all questions related to your medical examination of this candidate. Do
the following steps:
1. Review the candidate’s job duties/responsibilities for which he/she is being employed to
make sure that you are familiar with the relevant job demands and working conditions of the
specific position for which the candidate is being considered. Additional information such as job
descriptions; critical knowledge, skills, or tasks lists; or other items may be provided. A list of job
duties and responsibilities should be provided to you by the hiring agency along with this form.
2. Complete the patient information at the bottom of this page and then conduct your physical
exam.
3. Review the patient’s Medical and Physical History. A Report Form may be provided to you
by the candidate or you may use the form commonly used in your medical practice.
4. Answer all questions by checking the appropriate block on each page and providing any
comments necessary for the hiring agency’s assessment.
5. SIGN & DATE on the appropriate page of this form and provide your address & phone #.
(Please note that this exam must be conducted by a licensed physician or osteopath, and the
form signed by a licensed physician or osteopath only. (Forms signed by other personnel such
as nurses, nurse practitioners, physician’s assistant, or other staff will be rejected.)
6. Give all forms to the candidate for return to the hiring agency.
This candidate, if certified, will have the prerequisites necessary to gain employment at any law enforcement
agency in the State of Georgia, including but not limited to the current place of employment. Peace officers are
charged with the responsibility of enforcing criminal laws and are subject to deal with violent individuals and
situations. Officers are often required to defend themselves and others from physical attacks, subdue resisting
individuals, and make decisions under stress concerning the use of deadly force. These types of positions
generally require a high level of physical capability.
O.C.G.A. §35-8-8 and POST Rule 464-3-.02 require that candidates be found, after examination by a licensed
physician or surgeon, to be free from any physical, emotional, or mental conditions which might adversely affect
his/her exercising the powers or duties of a peace officer. Please note that your answers are intended to
provide the hiring agency with the most useful information possible to base an employment decision, confirm to
the Georgia Peace Officer Standards and Training Council that this candidate meets the requirements set forth
in POST Rule 464-3-.02, and in your medical opinion, this candidate is capable of safely completing the
required training and safely performing the necessary job duties.
Name of Agency Contact (Agency Person Processing Application)
Contact Phone#
(Area Code) - Number
( )-
-
EXT
EMAIL ADDRESS OF AGENCY CONTACT
@
SECTION 1: TO BE COMPLETED BY LICENSED EXAMINING PHYSICIAN
Social Sec#
Last Name
DATE OF BIRTH
Suffi
x:
(mm/dd/yyyy)
Maiden Name
//
Job Applied for by the candidate is:
First Name
HEIGHT
ft
in
Middle Name
WEIGHT
lbs
(without shoes
& coat)
SEX:
Pg __
Of __
Initial
____
Physician’s Affidavit - PAGE 2 of 3
1.) In your opinion, does the candidate have, or is the candidate likely to develop, any physical
symptoms or limitations that could impair performance in this position?
No
Proceed to question 2
Describe additional tests or information required prior to making final determination.
Indeterminate
Yes
Describe the impact of these limitations including the following criteria:
• Job functions affected
•
Nature & degree of severity
•
Duration of impairment (if intermittent or temporary)
•
Likelihood(s) associated with this impact
2.) In your opinion, could the candidate’s performance in this position result in a risk to the health and
safety of the candidate or others?
No
Indeterminate
Yes
• Specific job duties/functions and/or working conditions that precipitate the risk:
•
Nature & severity of potential harm:
•
Impact of harm on self and/or others:
•
Likelihood(s) associated with this risk:
•
Imminence and duration of the threat;
Please describe any means, devices or work restrictions that could reduce or eliminate any identified risks to a
level not significantly greater than that posed by the average candidate. Include the manner in which the
accommodation needs to be implemented, maintained, and monitored; any side effects or risks associated with
the accommodation; and a revised estimate of the candidate’s viability in this position if it is implemented.
Pg __
Of __
Initial
____
Physician’s Affidavit - Page 3 of 3
3.) In summary, what is your overall evaluation of the candidate’s ability to safely perform the duties of
this position? (choose one below)
This candidate has no physical, emotional, or mental conditions that might adversely affect his/her
ability to perform the duties of a peace officer or take part in training programs relative to law
enforcement.
Comments:
This candidate has no physical conditions that might adversely affect his/her ability, but there are
some concerns that should be addressed regarding one or more emotional or mental conditions that
could adversely affect their ability. (Please state recommendations on how to address here.)
Comments:
This candidate has no emotional or mental conditions that could adversely affect their ability, but
there are some concerns that should addressed regarding one or more physical conditions that could
adversely affect their ability. (Please state recommendations on how to address here.)
Comments:
This candidate has one or more physical , emotional, or mental conditions that could adversely
affect their ability that need to be addressed. (Please state recommendations on how to address here.)
Comments:
SIGNATURE OF LICENSED
EXAMINING PHYSICIAN (required)
EXAMINING PHYSICIAN’S NAME (printed)
DATE (m/d/yyyy)
____________________________________________________
Last
First
ADDRESS OF LICENSED EXAMINING PHYSICIAN’S PRACTICE
________________________________________________________________________
Street
Phone:
Area Code+Number
(
)
________________________________________________________________________
City, State, Zip
SECTION 2: HIRING AUTHORITY’S ASSESSMENT
(TO BE COMPLETED BY HIRING AUTHORITY)
Based on the information provided by the physician and the candidate, it is my belief that the candidate meets
the state standards for this position and can safely perform the essential job demands of the position for which
they are being hired. If a reasonable accommodation is necessary for this individual and the state standards
are still met, I have attached a letter explaining the necessary accommodations.
SIGNATURE OF AGENCY HEAD OR DESIGNEE (required)
Accommodation Noted:. Check here if a letter from agency head giving details of
accommodation is attached (required). This letter indicates that the candidate
needs a reasonable accommodation which can be implemented without undue
hardship to the agency & still meets state standards.
DATE
GENERAL INFORMATION
(MAPEP)
Inquiry Authority/Use Statement
The collection of this information is authorized by O.C.G.A. 45-2-40. This information will be used to determine fitness for duty and to
provide protection to employees from potential harmful effects associated with this employment. Unless otherwise stated, this information
may be disclosed to the hiring agency, State agencies responsible for State benefits and workers' compensation programs, and, where
pertinent, to an appropriate law enforcement agency for investigation for prosecutive purposes or in a legal proceeding to which the hiring
agency is a party. As provided by the Americans With Disabilities Act of 1990 (Public Law 101-336), this information is to be filed
separately from other personnel records and is to be used only for legitimate, non-discriminatory hiring and placement purposes with
reasonable accommodation, where appropriate. Completion of this form is voluntary; however, if this information is not provided, the
individual may not receive the requested benefits or employment.
A: Completed by Appointing or Referring Office
(Type or Print in Ink)
1. Employee Name:________________________________________________________
Last,
3. Race: ___________________
First
4. Sex:
Female
Middle
Male
//
5.________________
Date of Birth
7. Address:______________________________________________
*****
2.________-______-_________
Social Security Number
6. _______________________
Daytime Telephone Number
8. Position Title:_____________________________
______________________________________________________
9. Position Number:__________________________
______________________________________________________
10. Location of Position:_______________________
11. Direct Contact for Position Information
a. Name: _______________________________
f. Dept.: _____________________________________________
b. Title: ________________________________
g.. Unit: ______________________________________________
c. Telephone: ____________________________
h. Address: __________________________________________
d. E Mail:
____________________________
e. Fax Number: __________________________
__________________________________________
__________________________________________
12. Indicate type of job information used for medical review (check all that apply):
Job description
Other (please specify)_____________
Performance standards
______________________________
Functional requirements analysis
______________________________
Environmental factors analysis
______________________________
13. Check job category:
Category 1 Sedentary
Category 2 Active
Category 3 Food Handling
Category 4 Health-related
Category 5 Law Enforcement
14. Describe any notable or unusual job requirements or working conditions: (continue on separate page, if needed)
_________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
MS 10-50 February 15, 2005 (Page 1 of 2)
PO/CO, Page 5
15. Were any "reasonable accommodations" needed?
(continue on separate page, if needed)
Yes
No
If "Yes," describe:
_____________________________________________________________________________________________
_______________________________________________________________________________________
____________________________________________________________________________________________________________
16. ____________________________________________________________________
(Type or Print Official Contact's Name)
17. _______________________________________________
Signature of Official Contact
18._________________________________
Date
B: Completed by Applicant/Employee
1. Have you been provided detailed information on the duties of this position?
2. Do you understand the functional requirements and environmental factors of this position?
3. Are you capable of performing the duties and responsibilities of this position (with reasonable
accommodations, if necessary, as described in Section A, Item #15)?
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
For the following questions, explain a "Yes" answer in the space provided below
4. Have you ever been employed by the State of Georgia?
5. Have you had a physical examination for employment with the State of Georgia within the
past twelve months period?
6. Is there anything in your past medical history, of which you have knowledge, that would
prevent your being able to perform the duties of this position?
Explanation of items 4-6 checked "Yes." Enter item number before each comment.
_________________________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________________________________________________________________________________________
I certify that all information given by me in connection with this medical assessment is true to the best of my
knowledge and belief. I agree and understand that any misstatements of material facts may cause forfeiture on my
part of all right to employment in the service of the State of Georgia; may result in dismissal after appointment; or
may result in loss of entitlement to disability retirement benefits. My signature also indicates that I understand all of
the questions on this form
7. _________________________________________________________
Signature of Employee
8._____________________________
Date
MS 10-50 February 15, 2005 (Page 2 of 2)
PO/CO, Page 6
(MAPEP)
Health Information Checklist
This checklist contains questions regarding your medical history and health. The primary use of this information will
be to alert the employer and applicant of conditions that could negatively impact the health of customers or coworkers. This information may be used to determine fitness to perform job duties. This information will be handled
in a confidential manner. It is essential that you answer all questions truthfully and completely. False or incomplete
information may result in disqualification or termination if hired.
Completed by Applicant/Employee
Section I
Date: ______________________
Employee Name: ___________________________________
Last,
First
*****
Social Security Number _______-_______-_______
Middle
Employing Agency: ___________________________________________
Date Employed: ______________________________
Section II
Have you now, or ever had the following?
Yes
No
1. Loss of sight of both eyes. Loss of uncorrected (without glasses or
contact lens) vision of more than 75% bilaterally (vision of 20/160 or
J* or worse using both eyes).
2. Diabetes
3. Tuberculosis
4. Epilepsy (convulsions, seizures or fits)
5. Ankylosis (immobility) of major weight bearing joints (ankles, knee,
hip)
6. Any permanent condition which causes 20% (or more) impairment of
a foot, leg, hand, arm, back, or the body as a whole
7. Arthritis which is a hindrance to employment
9. Amputated (loss of) foot, leg, arm, or hand
10. Parkinson’s disease (Paralysis Agitans)
11. Cerebral palsy
12. Multiple sclerosis
13. Mental retardation (intelligence quotient within the lowest two
percent of the general population)
Yes No
14. Psychoneurotic disability following confinement for treatment in a
recognized medical or mental hospital for a period in excess of six
months.
15. Hemophilia
16. Sickle cell anemia
17. Cardiovascular (heart or blood vessel) disease
18. Total occupational loss of hearing (loss of over half of hearing in
each ear)
19. Compressed air sequelae (damage to lungs, ruptured ear drum, etc
e to air concussion, blasting, explosion, etc.)
20. Muscular dystrophy
21 Hyperinsulinism (hypoglycemia)
22. Residual disability from poliomyelitis (Disability due to polio)
23. Ruptured intervertebral (back) disc
23. Chronic osteomyelitis (bone infection)
24. Hepatitis
REMARKS:____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
_________________
__________________________________________________
MS 10-500 July 1, 2006 (Page 1 of 1)
___________________________
Date
PO/CO, Page 7
STATE OF GEORGIA
*****
Name______________________________________ Soc. Sec. No. _______-______-________
MEDICAL AND PHYSICAL
Job Title ___________________________________ Department _________________________
EXAMINATION PROGRAM
MEDICAL HISTORY REPORT
Job Category (circle one) 1
2
3
4
5
The purpose of these questions is to gather information concerning your health and physical condition, both now and in the past. This information
will be used only to determine whether you can safely perform the duties of the job for which you are being considered. Please answer all of the
following questions as fully and completely as you can. If you don’t understand a question, or are unsure of how to answer it, leave it blank and
request assistance.
I certify under penalty of perjury, that the information given by me is true to the best of my knowledge and belief. I agree and understand that any
misstatements of material facts may cause forfeiture on my part of all right to employment in the service of the State of Georgia, may result in
dismissal after appointment; or may result in loss of entitlement to disability retirement benefits. My signature also indicates that I understand all of
the questions on this medical history form.
EMPLOYEES’ SIGNATURE: _______________________________________ DATE: ______________________
Individual History – To Be Completed By Applicant/Employee (Use Ink)
A. MEDICAL CONDITIONS. Check every item. Do you have or have you ever had any of the following: (If “Yes,” give date of most recent
occurrence and explain on page 3.)
Health Condition
HEAD, NOSE, MOUTH AND THROAT
Yes
Year
Health Condition
No
Year
28. Glasses
1. Persistent or severe headaches
29. Contact lenses
2. Frequent nose bleeds
RESPIRATORY SYSTEM (lungs & breathing)
3. Frequent nasal congestion
30. Persistent or severe colds
4. Persistent or severe sinus condition
31. Persistent or severe cough
5. Bleeding gums
32. Coughing blood
6. Persistent or severe dental condition
33. Asthma or breathing difficulty
7. Hoarse when don’t have cold
34. Emphysema
8. Difficulty swallowing
35. Pneumonia
9. Persistent sore throat
36. Tuberculosis
10. Loss of taste or smell
37. Other lung or breathing condition:
11. Head injury
CARDIOVASCULAR SYSTEM (heart & blood vessels)
12. Other head, nose, mouth or throat conditions:
39. Heart attack
EARS AND HEARING
39. Hardening of the arteries (Arteriosclerosis)
13. Hearing difficulties
40 High or low blood pressure
14. Use hearing aid
41. Heart murmur
15. Ringing in ears (tinnitus)
42. Palpitations or irregular heart beat
16. Perforated ear drum
43. Episodes of chest pains, tightness, discomfort
17. Persistent or severe ear infection
44. Shortness of breath
18. Other ear or hearing conditions
45. Varicose veins
EYES AND VISION
46. Swelling of ankles, feet or legs (edema)
19. Glaucoma
47. Leg pains, cramps
20. Cataract
48. Other cardiac conditions:
21. Eye irritations (itching or burning)
GASTROINTESTINAL SYSTEM (stomach & intestines)
22. Eye infection
49. Persistent or severe nausea or indigestion
23. Defective vision
50. Persistent or severe stomach pain
24. Color blindness
51. Vomiting blood
25. Injury to eye
52. Persistent or severe vomiting
26. Eye surgery
53. Hernia (rupture)
27. Double vision
54. Stomach or duodenal ulcer
MS 10-52, February 15, 2005 (Page 1 of 3)
Yes
PO/CO, Page 8
No
Health Condition
55. Colitis
Yes
Year
No
Health Condition
100. Knee surgery
57. Change in bowel habits
101. Foot problems
58. Black stool or blood in stool
102. Bone infection
59. Persistent or severe constipation
103. Broken or fractured bone
60. Persistent or severe diarrhea
104. Persistent or severe muscle aches or pains
61. Pancreatitis
105. Other Musculoskeletal conditions:
62. Appendicitis
ENDOCRINE/METABOLIC SYSTEM
63. Other conditions of stomach or intestines
106. Diabetes
LIVER, SPLEEN & GALLBLADDER
107. Thyroid condition or disease
64. Cirrhosis
108. Hypoglycemia
65. Hepatitis
109. Unexplained weight gain or loss
66. Yellow jaundice
110. Unusual loss or growth of body hair
67. Gallstones
111. Gout
68. Other conditions of liver, spleen or gallbladder
112. Osteoporosis or other bone disease
KIDNEYS & URINARY TRACT
SKIN
69. Kidney stones
113. Rash
70. Kidney infection
114. Hives
71. Blood or pus in urine
115. Moles that bleed or get larger
72. Pain or burning when urinating
116. Change in color of skin (other than suntan)
73. Frequent urination
117. Frequent boils/abscesses
74. Albumen or protein in urine
118. Trouble with fingernails
75. Prostate condition
119. Small itching blisters on the side of fingers or palms
76. Burning discharge from penis
120. Sores that do not heal
77. Other conditions of kidneys or urinary tract
121. Other skin conditions:
REPRODUCTIVE SYSTEM (FEMALES ONLY)
BLOOD/LYMPH (hematologic) SYSTEMS
78. Pregnant at present
122. Anemia
NEUROLOGICAL (Nervous) SYSTEM
123. Bleeding disorder
79. Epilepsy, convulsions, seizures
124 Sickle cell disease or trait
80. Periods of blackouts/loss of consciousness
125. Phlebitis/blood clot
81. Fainting spells
126. Blood transfusion
82. Dizzy spells (vertigo)
127. Chills, fever, night sweats
83. Memory difficulty
128. Lymph node or glandular swelling that persists
84. Tremor of the hands or head
129. Other conditions of blood or lymph:
85. Paralysis of any type
CANCER
86. Stroke
130. Surgery
87. Severe numbness, tingling or weakness
131. Radiation therapy
88. Dyslexia/learning difficulty
132. Chemotherapy
89.
133. Immunotherapy
MUSCULOSKELETAL SYSTEM
No
134. Hormone therapy
90. Arthritis
135. Breast
91. Bursitis/tendonitis
136. Bone
92. Swollen or painful joints
137. Skin
93. Dislocations
138. Other
94. Painful or trick shoulder
PSYCHOLOGICAL/MOOD
95. Elbow problems
139. mental problem requiring hospitalization
96. Wrist or hand problems
140. Suicidal/attempted suicide
97. Back pain
141. Active psychosis
98. Back surgery
142. Drug, narcotic or alcohol
Year
99. Trick or locked knee
56. Hemorrhoids or piles
Other conditions of neurological (nervous) system:
Yes
PO/CO, Page 9
Health Condition
Yes
Year
No
Health Condition
143. Persistent or severe depression/worry
ALLERGIES (caused by)
144. Other psychological conditions:
152. Medication
INFECTIOUS OR CHILDHOOD DISEASES
147. Rheumatic fever
Meningitis/encephalitis
153. Food
146. Polio
154. Soaps or detergents
148. Mumps
155. Pollen
149. Measels
156. Insect bites/scales
150. Venereal Disease
157. Other:
Yes
151. Other:
Explanation of items checked “Yes.” Enter item number (1-157) before each comment.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
B. CURRENT MEDICATIONS: ____________________________________________________
_________________________________________________________________________________
C. SURGICAL HISTORY
Have you ever had surgery?
Yes
No
[If “Yes, complete the following information about each surgery]
TYPE OF SURGERY
DATE (Mo/Yr)
1. __________________________________________
_____________
__________________________________________
_____________
D. HOSPITALIZATION HISTORY
Have you ever been hospitalized?
Yes
No
[If “Yes,” complete the following information about each hospitalization.]
REASON FOR HOSPITALIZATION
1. ___________________________________________
DATE (Mo/Yr)
_____________
2. ___________________________________________
_____________
3. ___________________________________________
_____________
RESTRICTED/MEDICAL
PO/CO, Page 10
Year
No
ACKNOWLEDGEMENT STATEMENTS - Page 1
Read and sign acknowledgement statements listed below.
APPLICABILITY:
All facilities and offices of the Georgia Department of Corrections
PURPOSE:
To provide guidance to the employees of this department in compliance with the Civil Rights
Act of 1964 (Title VII, amended) and the requirements of the American with Disabilities
Act of 1990 (ADA)
Non-discrimination & Equal Access Policy
As Commissioner of the Department of Corrections, I stand firmly committed to the continuing objective of making "equal employment opportunity" the
standard practice of this agency. The responsibilities of management are addressed in the rules, regulations, policies, and standard operating
procedures of the Department. Nonetheless, I expect to find compliance, cooperation, and individual commitment from each employee, in the
attainment of the Department's EEO & non-discrimination goals. Adverse criticism of an individual or group because of their disability, race, sex, age,
religion, or national origin will not be tolerated.
We must continue to examine all internal employment practices to secure meaningful and efficient utilization of each employee's skills. All
impermissible barriers and roadblocks for applicants and employees must be removed. It is imperative that we provide job entry and career
advancement based upon talent and merit.
We will provide equal access in the delivery of our programs, services, and activities to all qualified individuals. This policy includes our efforts to
ensure non-discrimination with respect to any prisoner, probationer or detainee in GDC's custody. It is further understood that we will provide unbiased
service to any persons having legitimate business with this Department, and shall conduct our programs, services and activities in the most integrated
setting appropriate to State correctional and detention facilities (to include consideration of the particular custody level and status of an inmate,
detainee or probationer).
Prohibitions against Harassment & Retaliation
Harassment and acts of retaliation are prohibited because such behavior has an adverse impact upon working relationships, internal operations, and
our general work place conditions. Prohibited harassment includes use of epithets, slurs, negative stereotyping, and creation or distribution of written,
electronic or other graphic material which degrades an individual or group because of their disability (physical or mental impairment), race, sex, age,
religion or national origin. As such, everyone is hereby forewarned that such conduct, by any person under the jurisdiction of this agency, will form the
basis of disciplinary and/or civil action, which, presumptively, shall be termination.
Administrative Mandates
NECESSARY CONFIDENTIALITY WILL BE PROVIDED. An employee or other individual who, in good faith, believes he/she has been the victim of
(or reports) acts of unlawful discrimination or harassment, will not be subject to retaliation or reprisal of any kind. I strongly encourage complainants
and/or witnesses to report prohibited behavior to unit supervisors or managers. In an on-going process, specific individuals will be designated to
oversee the implementation of the laws and regulations, which govern our employment practices, programs, delivery of services, and access to
correctional activities. Transition Plans, agency guidelines, and local operating procedures will be developed to help ensure compliance and
successful accomplishment of our Equal Opportunity objectives.
Commissioner, Georgia Department of Corrections
My signature below acknowledges that I am aware that these statements will become a part of my
official personnel record. I understand that any violation of the ab ove policies and/or rul es could
result in disciplinary action, to include dismissal from employment.
Signature
Date
______________________________________________
Printed Name
PO/CO, Page 11
Acknowledgement of GDC Rule #125-2-1-07
Employees shall not, without the express written approval of the appropriate Division Director, maintain personal association with, engage in personal
business or trade with, or engage in non job-related correspondence with, or correspondence in behalf of, or for, known inmates, active probationers, or
parolees. Current employees, who are related by law to any inmate, detainee, or active probationer or parolee, shall be governed by this same
standard.
Employee Statement
I understand that my continued employment is contingent upon my meeting all minimum employment requirements of the Department of Corrections, to
include a background investigation and medical examination, and successful completion of specified training. I further understand that should I fail to
meet any such requirements, my employment may be terminated.
I state that I have never been arrested for any offense whatever, other than as listed on my application and State Security Questionnaire. I fully
understand that my fingerprints will be sent to the Federal Bureau of Investigation and other law enforcement agencies, and should the record of any of
these agencies reflect any arrest not disclosed at the time of my appointment, my employment will be immediately terminated.
I state that I am ____ am not _____ a former inmate, current or former parolee, current or former probationer.
Agreement for Use of State Property
I understand that as an employee of the Georgia Department of Corrections, I am fully responsible for any items of state property that are issued to
me. The following conditions apply at the expiration of my employment:
Separation: Upon separation of my employment with the Department or upon a job change within the Department, I agree to return all weapons,
ballistic vests, computers, cell phones, badges or full sets of uniforms to the Department.
I agree to pay published prices for any other state-issued property.
Repayment: If I fail to pay the amount due, I authorize the amount to be deducted from any monies due me in the form of terminal leave pay. In the
event the monies held are not sufficient to cover the amount due, I understand that I am still fully responsible for repayment.
Criminal Action: I understand that criminal action may be taken against me, up to and including issuance of a warrant and prosecution for failure to
return state property.
Business Transactions with Other State Agencies - O.C.G.A 45-10-25
Employees are advised that certain business transactions and part-time employment with other State agencies is prohibited by law. To avoid illegal
business activity and potential conflicts of interest, particular arrangements must be made. Generally, all business transacted with the State of Georgia
by any public official or employee, whether a) for him/herself, b) on behalf of any business, or c) for any business in which the employee or any familymember has a substantial interest, must be disclosed. Therefore, no state employee should do business (other than his/her regular employment
responsibilities) with any state agency, until they have become thoroughly familiar with the legal requirements.
Definitions:
A) "Business transacted" means the purchase, sale, or leasing of any personal property, real property, or services on behalf of one's self or on behalf of
any third-party agency, broker, dealer, or representative.
B) "Any business" means any corporation, partnership, proprietorship, firm, enterprise, franchise, association, organization, self-employed individual,
trust, or other legal entity.
C) "Family" means spouse and legal dependents.
D) "Substantial interest" means the direct or indirect ownership of more than 25% of the assets or stock of any business.
Alcoholic Consumption & Purchase Policy
Each employee of the Georgia Department of Corrections (GDC) must conduct himself/herself in a manner, which reflects favorably upon the
Department and the State of Georgia, as public employers. It will be a violation of this policy for GDC employees to: a) Consume alcoholic beverages or
to be intoxicated while on the premise of any work place (e.g., office, state-leased property, building or facility) under the Department's jurisdiction or
control. b) Consume alcoholic beverages or to be intoxicated on duty, during his/her working hours. c) Purchase or consume alcoholic beverages while
dressed in required-uniforms (e.g., correctional officer's, food service employee's, probation officer's attire). d) Purchase, handle, or transport alcoholic
beverages while travelling in a state vehicle or performing assigned duties.
official personnel record. I understand that any violation of the above policies and/or rules could
Revised 12/10
Signature
Date
Printed Name
Witness
32&2, Page ACKNOWLEDGEMENT STATEMENTS - Page 3
Drug Free Work Place
Congress passed a law called The Drug-Free Work Place Act of 1988, which is designed to ensure that any work performed under federal
contracts or federal grants is accomplished in a drug-free work environment. Employees of the Georgia Department of Corrections (GDC)
are prohibited from engaging in all illegal activity pertaining to the manufacture, distribution, dispensation, possession, or use of illegal drugs,
at any time. It is the position of this Department that, all such illegal activity, even during non-working hours, clearly affects the employee's
ability to perform his/her public duty in an efficient and effective manner. Compliance with this standard of conduct is a condition of
employment for all GDC employees. This GDC policy requires every agency employee to notify the appropriate Appointing Authority, in
writing, within five (5) calendar days of his/her arrest or conviction for violating any drug-related law, (including a plea of nolo contendere) in
any jurisdiction, regardless of whether it involved a work place or non-work related incident.
Business Activities for Personal Gain or Profit Policy
Compliance with established standards of conduct is a condition of employment for all Georgia Department of Corrections (GDC)
employees. An employee's behavior or conduct on the job must reflect favorably upon the Department as a public employer. As such, it shall
be prohibited for any GDC employee to: a) Use or permit the use of state property for personal gain, profit or personal business. b) Conduct
personal business for profit, while in the work place or during his/her working hours. All employees are advised not to borrow from or lend
money to other employees; however, it is expressly prohibited for a GDC employee to lend money to a Department employee, for profit. c)
Knowingly accept personal gifts or favors from any non-employee whose business interacts or interfaces with the Department of Corrections.
d) Knowingly have personal involvement with, engage in personal business (or trade) with, correspond with or on behalf of inmates,
detainees or any active probationers or parolees; without the express written approval of the appropriate Appointing Authority.
Note: Current employees who are related by law to any inmate, detainee, or active probationer or parolee, shall be governed by this same
standard.
Sexual Assault Awareness Statement
Whenever a correctional officer or other individual with similar supervisory or disciplinary authority over a person in custody has sexual
contact with that person, he/she has committed a sexual assault against a person in custody. Sexual contact means any contact for the
purpose of sexual gratification of the actor with intimate parts of a person he/she is not married to. The law defines intimate parts as the
genital area, groin, inner thighs, buttocks or breasts.
Georgia Crime Information Center
Access to Criminal Justice Information, as defined in GCIC Council Rule 140-1-.02 (amended), and dissemination of such information are
governed by state and federal laws and GCIC Council Rules. Criminal Justice Information cannot be accessed or disseminated by any
employee except as directed by superiors and as authorized by approved standard operating procedures which are based on controlling
state and federal laws, relevant federal regulations, and the Rules of the GCIC Council. O.C.G.A. 35-3-38 establishes criminal penalties for
specific offenses involving obtaining, using, or disseminating criminal history record information except as permitted by law. The same
statute establishes criminal penalties for disclosing or attempting to disclose techniques or methods employed to ensure the security and
privacy of information or data contained in Georgia criminal justice information systems. The Georgia Computer Systems Protection Act
(O.C.G.A. 16-9-90 et seq) provides for the protection of public and private sector computer systems, including communications links to such
computer systems. The Act establishes four criminal offenses; all major felonies, for violations of the Act: Computer Theft, Computer
Trespass, Computer Invasion of Privacy, and Computer Forgery. The criminal penalties for each offense carries maximum sentences of
fifteen (15) years in prison and/or fines up to $50,000, as well as possible civil ramifications. The Act also establishes Computer Password
Disclosure as a criminal offense with penalties of one (1) year in prison and/or a $5,000 fine. The Georgia Criminal Justice Information
System Network is operated by the Georgia Crime Information Center in compliance with O.C.G.A. 35-3-31. All databases accessible via
CJIS Network terminals are protected by the Computer Systems Protection Act. Similar communications and computer systems operated by
municipal/county governments are also protected by the Act.
The 1996 Georgia Laws Act 816
The 1996 Georgia Laws Act 816, provides that all positions filled on or after July 1, 1996, by new hires shall be included in the unclassified
service, and will not be covered by State Merit System. The Georgia Department of Corrections reserves and retains the right to make
changes in the terms and conditions of any employment relationship as the Department determines to be necessary or appropriate for the
effective and efficient administration of the Department and its public mission. All initial employment relationships commencing on or after
July 1, 1996 are "AT WILL" in nature, meaning that the employment may be altered or terminated at any time, as required by the
Department's business and/or budgetary needs.
official personnel record. I understand that any violation of the above policies and/or rules could result
in disciplinary action, to include dismissal from employment.
Signature
Printed Name
Date
PO/CO, Page 13
IMPORTANT NOTICE TO EMPLOYEES
SOP IV008-0001
Attachment 3
Revised 09/01 /01
UNDERSTANDING THE USE OF FLSA COMPENSATORY TIME
EMPLOYEES CANNOT WAIVE THEIR RIGHT TO COMPENSATION UNDER THE FLSA
I, _______________________________________________________ , do acknowledge that as part of the terms and conditions of my employment
with the Georgia Department of Corrections (hereinafter referred to as the Employer), I understand that:
1 . I may be required to work more than forty hours in a work week, or other maximum hours in a work period established by the Fair Labor Standards
Act of 1938 (hereinafter referred to as the FLSA), as amended now and in the future, for law enforcement, fire protection, hospital or other special
groups of employees; and
2. If I am required to work more than the maximum number of hours permitted by the FLSA, my employer has the option of paying for such overtime
in cash at the rate set in the FLSA or by compensatory time off at the rate of one and one-half hours for each hour of employment for which
overtime compensation is required by the FLSA; and
3. My Employer has reserved the right to purchase any compensatory time accrued by me at the rate set in the FLSA.
4. I understand that I may be directed to use accumulated FLSA compensatory time in lieu of paid leave.
(ORIGINAL MUST BE SUBMITTED TO CENTRAL PERSONNEL ADMINISTRATION WITH HIRING PACKAGE)
Record Retention: Permanent retention in the employee's official and local personnel files.
IMPORTANT NOTICE TO EMPLOYEES
The Georgia Department of Corrections wishes to reaffirm that it requires all non-exempt employees to:
SOP IV008-0001
Attachment 4
Revised 09/01 /01
REPORT ALL TIME WORKED
This means that you must:
 record the exact hour and minute that you begin any work
 record the exact hour and minute that you stop all work
 make these entries on each day you work
 be absolutely certain that you have recorded all work time
 personally make and initial any changes in your timesheet or timecard which might occasionally be necessary
The Georgia Department of Corrections relies upon your personal time entries in calculating your pay and in maintaining your payroll records. Thus, a
failure to accurately record all time worked will mislead the Department and can result in discipline or discharge. It is a violation of these policies either to
under-report or to over-report your work time. Remember: accuracy is the key--not just the appearance of accuracy.
No deviation from these instructions is permitted. No one may ask or direct that a non-exempt employee work "off the clock", "for free", or "on his or her
own time". Any non-exempt employee who is not being paid in accordance with these policies or who has knowledge that the policies are being violated
should immediately report this in confidence to the Department Personnel Director at (404) 656-4730. Your report will remain confidential, and you will
not be punished for making such a report.
My signature below acknowledges that I am aware that these statements will become a part of my official
personnel record. I understand that any violation of the above policies and/or rules could result in disciplinary
action, to include dismissal from employment.
_________________________________
Date
Employee ID
__________________________________________________
Employee Signature
Printed Name
PO/CO, Page 14
ACKNOWLEDGEMENT STATEMENTS -Page 5
Security Positions
Random Drug Screening
During the 1990 legislative session, the Georgia General Assembly passed Act 1445 which requires random drug screening of certain state employees.
The Act covers those employees who are required to obtain Peace Officer Standards and Training (P.O.S.T.) certification and who occupy positions
where '...inattention to duty or errors in judgment while on duty will have the potential for significant risk of harm to the employee, other employees, or
the general public.' (O.C.G.A. 45-20-90 (3). In accordance with the provisions of this law, your department head has determined that the position for
which you have been selected shall be subject to random drug screening.
It is very important that you fully understand the requirements of this law and the consequences that might result from its application. The law mandates
that any employee whose drug screening indicates the illegal use of drugs or marijuana shall be terminated from employment. The law does not permit a
second chance or the imposition of any lesser penalty. In addition, any employee who refuses to submit to drug screening, or who fails to appear for
drug screening after being directed to so appear, shall be terminated from employment. An employee terminated for any of these reasons is disqualified
from employment with Georgia Department of Corrections for a period of two years.
Sleeping on Duty
Sleeping on duty by an employee whose job responsibilities include direct supervision of inmates will not be tolerated.
If I commit this offense, it may result in my termination.
If I fail to report a co-worker sleeping on duty, it may result in my termination.
Condition of Employment
I understand that my employment is conditional upon the successful completion of the academy entrance examination administered by the Department
of Corrections pursuant to O.C.G.A 35-8-8(a) (9).
Signature
Date
_________________________________________
Printed Name
PO/CO, Page 15
Domestic Violence Awareness Statement
I understand that an amendment to the Federal Gun Control Act prohibits any person convicted of a misdemeanor crime of domestic
violence from shipping, transporting, possessing or receiving firearms or ammunition. I also understand that it is unlawful for a person
to sell or otherwise dispose of a firearm or ammunition to any person knowing or having reasonable cause to believe that the recipient
has been convicted of such a misdemeanor. I understand that this prohibition applies to all law enforcement officers.
I understand that the "misdemeanor crime of domestic violence" is defined in the law as:
1. A misdemeanor under Federal or State law; and
2. Has, as an element, the use or attempted use of physical force, or the threatened use of a deadly weapon by a current or former
spouse, parent or guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating
with or has cohabitated with the victim as a spouse, parent, or guardian, or by a person similarly situated to a spouse, parent, or
guardian of the victim.
This definition includes all misdemeanors that involve the use or attempted use of physical force if the offense is committed by one of
the defined parties. This is true whether or not the State statute or local ordinance specifically defines the offense as a domestic
violence misdemeanor. Also, the prohibition applies to persons convicted of such misdemeanors at any time, even if the conviction
occurred prior to the new law's effected date, September 30, 1996.
I understand that if I am found to have been convicted of such an offense that I will no longer be able to possess a firearm or
ammunition to use in the performance of my official duties and my duties will be changed from those requiring POST certification and
possibly dismissal from the department.
I understand that the department will conduct annual reviews of my record to determine if I have firearms disability under this law. I
also understand that it is my responsibility to notify my appointing authority of any arrests or convictions as soon as possible, including
but not limited to domestic violence misdemeanors.
My signature below acknowledges that I am aware that this statement will become a part of my
Signature
Date
__________________________________________________
Printed Name
Revised 2010
Notary or Witness
PO/CO, Page 16
Computer Use and Security Awareness Acknowledgment
I acknowledge that I have read and fully understand the Georgia Department of Corrections (GDC) rules and
procedures governing technology security of computer resources, networks, computer applications, programs,
and/or systems as outlined in SOP IVJ01-0001, Technology Policies and Procedures, and any others that may
be applicable. I have also read the following information and fully understand the requirements:
1. I will not divulge any of my system passwords, to any individual, for any reason, while employed with
the Department.
2. I will not leave my computer workstation accessible during my absence. I understand that I am
required to ensure that my computer workstation has a Screen Saver with PASSWORD, set to a five
(5) minute time limit.
3. I will not proceed to perform diagnostic tests or procedures on any office/center/facility computer
equipment, to include printers, without consulting either OIT (Office of Information Technology), a
facility Operations Analyst, the Division Information System Coordinator (DISC), or designated
information systems support individual for the office/center/facility.
4. I will not move or remove any office/center/facility computer equipment without consulting with OIT, a
facility Operations Analyst, the Division Information System Coordinator or a designated information
systems support individual for the office/center/facility.
5. I will not share information acquired by any GDC system with unspecified employees of this department
or any other state department or the Public without specific approval from the Appointing Authority.
6. I understand that I am prohibited from installing any program software not explicitly purchased for
departmental use unless I receive the written consent of my Appointing Authority and the approval of
OIT.
7. I understand that State-provided computer systems are intended for public business and that my use of
the internet, e-mail or other systems may be recorded and monitored. I understand that use or access
of the internet for pornographic, obscene, or other improper purposes is prohibited.
8. I understand that under Georgia Law Code 16-9-93, Section 3, Subsection E, "Computer Password
Disclosure," any person who discloses a number code, password, or other means of access to a
computer or computer network knowing that such disclosure is without authority and which results in
damages (including the fair market value of any services used and victim expenditure) to the owner of
the computer or computer network in excess of $500.00 shall be guilty of the crime of computer
password disclosure.
I fully understand that any violation of GDC procedures and rules regarding the use of the Internet or other
Department provided software or programs may result in disciplinary action up to and including dismissal from
my position, and may include civil and/or criminal prosecution.
Signature:
_______________ ____________ Date:______________________
Printed Name:_____________________________________________ Employee ID#:__________________
Retention Schedule: Retain permanently in the official personnel file.
Revised 10/10
PO/CO, Page 17
OMB No. 1615-0047;; Expires 08/31/12
Form I-9, Employment Eligibility Verification
Department of Homeland Security U.S. Citizenship and Immigration Services
Instructions
Read all instructions carefully before completing this form. Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155.
in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)).
Preparer/Translator Certification
The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his or her own. However, the employee must still sign Section 1 personally.
Section 2, Employer
What Is the Purpose of This Form?
The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.
When Should Form I-9 Be Used?
All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9.
Filling Out Form I-9
Section 1, Employee
This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-
Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.
Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.
Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an employment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present
For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document.
If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.
Employers must record in Section 2:
1. Document title;;
2. Issuing authority;;
3. Document number;;
4. Expiration date, if any;; and 5. The date employment begins. Employers must sign and date the certification in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. Employers are still responsible for completing and retaining Form I-9.
Form I-9 (Rev. 08/07/09) Y For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information."
Section 3, Updating and Reverification
Employers must complete Section 3 when updating and/or reverifying Form I-9. Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in Section 1 (if any). Employers CANNOT specify which document(s) they will accept from an employee.
A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A.
B. If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.
C. If an employee is rehired within three years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B;; and:
1. Examine any document that reflects the employee is authorized to work in the United States (see List A or C);;
2. Record the document title, document number, and expiration date (if any) in Block C;; and
3. Complete the signature block.
Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing Section 3. What Is the Filing Fee?
There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below. USCIS Forms and Information
Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website at www.uscis.gov/e-verify or by calling 1-888-464-4218.
General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov.
Photocopying and Retaining Form I-9
A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.
Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.
Privacy Act Notice
The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a). This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States. This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.
Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.
To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218.
EMPLOYERS MUST RETAIN COMPLETED FORM I-9 DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS
Form I-9 (Rev. 08/07/09) Y Page 2 Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.
Form I-9 (Rev. 08/07/09) Y Page 3 OMB No. 1615-0047;; Expires 08/31/12
Form I-9, Employment Eligibility Verification
Department of Homeland Security U.S. Citizenship and Immigration Services
Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name: Last
First
Middle Initial Maiden Name
,,
Address (Street Name and Number)
Apt. #
Date of Birth (month/day/year)
Zip Code
Social Security #
//
City
State
,,
I attest, under penalty of perjury, that I am (check one of the following): I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
A citizen of the United States A noncitizen national of the United States (see instructions) A lawful permanent resident (Alien #) An alien authorized to work (Alien # or Admission #)
until (expiration date, if applicable - month/day/year)
Employee's Signature
Date (month/day/year)
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Preparer's/Translator's Signature
Print Name
Address (Street Name and Number, City, State, Zip Code)
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).)
List A
OR
List B
AND
List C
Document title:
Issuing authority:
Document #:
Expiration Date (if any):
Document #:
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
and that to the best of my knowledge the employee is authorized to work in the United States. (State
(month/day/year)
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative
Print Name
Title
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
Section 3. Updating and Reverification (To be completed and signed by employer.) A. New Name (if applicable)
B. Date of Rehire (month/day/year) (if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.
Document Title:
Document #:
l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Form I-9 (Rev. 08/07/09) Y Page 4 LISTS OF ACCEPTABLE DOCUMENTS
All documents must be unexpired
LIST A
LIST B
Documents that Establish Both Identity and Employment Authorization
OR
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-
readable immigrant visa
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
Documents that Establish Employment Authorization
Documents that Establish Identity AND
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Employment Authorization Document 3. School ID card with a photograph
that contains a photograph (Form I-766) 4. Voter's registration card
5. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form
LIST C
5. U.S. Military card or draft record
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
1. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States
2. Certification of Birth Abroad issued by the Department of State (Form FS-545)
3. Certification of Report of Birth issued by the Department of State (Form DS-1350)
4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
5. Native American tribal document
8. Native American tribal document
9. Driver's license issued by a Canadian government authority
For persons under age 18 who are unable to present a document listed above: 10. School record or report card
11. Clinic, doctor, or hospital record
6. U.S. Citizen ID Card (Form I-197)
7. Identification Card for Use of Resident Citizen in the United States (Form I-179)
8. Employment authorization document issued by the Department of Homeland Security
12. Day-care or nursery school record
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 08/07/09) Y Page 5 IVO13-0003
Attachment 1
Revised 5/15/09
GEORGIA DEPARTMENT OF CORRECTIONS
COMMISSIONER'S STATEMENT PROHIBITING UNLAWFUL HARASSMENT
(INCLUDING SEXUAL HARASSMENT)
It is the commitment of this Department to provide all personnel a work environment conducive to personal and
professional satisfaction, while at the same time achieving the goals and mission of this Department. The
Department wishes to provide all personnel with a clear understanding of unlawful harassment and its adverse
impact upon the working relationships within this Department and with outside parties. All personnel are hereby
forewarned that unlawful harassment and unlawful retaliation of any personnel of this Department by other
personnel or individual conducting business with the Department is unlawful, strictly prohibited by Departmental
policy, and a basis for disciplinary action which, presumptively, shall be termination.
Unlawful harassment includes verbal, electronic, written or physical conduct that disparages or shows hostility
or aversion toward an individual because of that person’s race, color, religion, gender, national origin, age or
disability. Sexual harassment includes unwelcome sexual reference, allusions, "humor," advances, requests for
sexual favors, and other verbal, written, electronic, or physical conduct or interactions of a sexual nature as
defined by the Departmental policy and procedures related to this subject. Employees shall report all events of
unlawful harassment and unlawful retaliation against themselves or others to any supervisor in the chain of
command, the Director, Human Resources (404) 656-4730, Deputy Personnel Director (404) 656-4730, the
Director, Internal Investigations (404) 656-4604 or the Communications Center (404) 651-6511 outside of
normal business hours.
Personnel who, in good faith, report unlawful harassment will be protected from retaliation or reprisals of any kind.
The initial report, and any subsequent investigation, will be treated with confidentiality. Confidentiality and
protection from retaliation will be provided to personnel who participate in any aspect of an investigation or any
subsequent disciplinary process.
Personnel are encouraged to help safeguard our organization from irresponsible behavior. We solicit your support in
promoting a work environment which will be free of unlawful harassment or other similarly inappropriate conduct.
Brian Owens
COMMISSIONER
I
hereby declare that I have read the Commissioner's Statement regarding unlawful harassment (including sexual
harassment) of personnel or individuals conducting business with the Georgia Department of Corrections. I further
understand that unlawful harassment is a violation of this policy and is a basis for disciplinary action which
presumptively, shall be termination. My signature below acknowledges that I am aware that this statement becomes
a part of my official personnel records.
Employee's Signature _____________________________________
Date Signed: ___________________
Employee's Printed Name ___________________________________
Employee ID#: _________________
Record Retention: Retain permanently in the official and local personnel file.
PO/CO, Page 20
SOPIVO14-0001
Attachment 1
Revised 12/15/06
Employee Standards of Conduct
ACKNOWLEDGMENT STATEMENT
This is to acknowledge that I have read the Department’s procedure governing
employee standards of conduct. As a condition of employment, I will abide by the terms
and conditions of this procedure. I understand that any violation of this procedure,
including any of the standards contained therein, may be the basis for disciplinary action,
including dismissal. I also understand that disciplinary action can be taken for matters
not covered by this procedure and that it does not create any new rights for me or for any
other employee of the Department of Corrections.
_____________________________________________
Employee Signature
_____________________
Date
______________________________________________________________________
Type/Print Employee Name
Employee ID:___________________________________________________________
Record Retention: Retain permanently in the local and official personnel file.
PO/CO, Page 21
GOVERNOR'S EXECUTIVE ORDER ESTABLISHING A CODE OF ETHICS FOR EXECUTIVE BRANCH
OFFICERS AND EMPLOYEES - Effective January 13, 2003
ACKNOWLEDGEMENT STATEMENT
This is to acknowledge that I have read the Governor's Executive Order Establishing a Code of
Ethics for the Executive Branch Officers And Employees. I understand that this Code of Ethics
applies to me. As a condition of employment, I will abide by the terms and conditions of this Code of
Ethics. I understand that any violation of this Code of Ethics, including any of the standards
contained therein, may be the basis for disciplinary action, including dismissal. I understand that the
standards contained in this Code of Ethics do not replace the Department of Corrections Employee
Standards of Conduct nor any existing statutory requirements, but is in addition thereto. I also
understand that disciplinary action can be taken for matters not covered by this procedure and that
it does not create any new rights for me or for any other employee of the Department of Corrections.
(10/10)
Type/Print Employee Name
Employee Signature
Date
Employee ID
PO/CO, Page 22
OATH OF OFFICE
I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States of
America and the State of Georgia, and that I will faithfully perform and discharge the duties of my office
without malice or partiality, to the best of my ability.
I further swear (or affirm) that I am not the holder of any unaccounted for public money due this state or
any political subdivision or authority thereof; that I am not the holder of any office of trust under the
government of the United States, any other state, or any foreign state which I am prohibited from holding
under the laws of the State of Georgia; and that I am otherwise qualified to hold office according to the
Constitution and laws of Georgia.
Print Name
Signature
Date
Work Site
IN WITNESS THEREOF this oath is witnessed and subscribed to by the following person who has
affixed his or her seal, this
day of
,
.
Witness/Notary Public
PO/CO, Page 23
CORRECTIONS DIVISION - PROBATION OPERATIONS
ACKNOWLEDGEMENT OF EMPLOYMENT CONDITIONS
The following constitutes an offer of employment according to the conditions set forth:
1.
Name of Appointee:
2.
Job Title:
3.
Effective Date of Appointment:
4.
Date to Report to Work (if different):
5.
Type of Appointment (circle one):
6.
Work Unit/Location:
7.
Pay Grade:
8.
Monthly Salary (Gross):
9.
Drivers License Verification and Number:
Classified
Number
Unclassified
State
It is understood that Probation Operations, Corrections Division, Department of Corrections is offering me
employment according to the above stated conditions. In accepting this position, I understand the following
conditions:
A.
It is the prerogative of the Department to assign the duties I am to perform, to set and modify the hours
of my work schedule and set and modify the location of my employment consistent with GDC SOP
IV005-0004.
B.
I am not to have any personal or business dealings with offenders under the supervision of the
Department.
C.
If I am being hired as a Probation Officer, Chief Probation Officer or Surveillance Officer, I must meet
the requirements as specified by the Peace Officers Standards and Training (POST) Council, the
Department of Corrections and Probation Operations, Corrections Division; otherwise, my employment
will be terminated.
D.
If I am being hired as a Probation Officer, I must maintain a telephone number.
E.
If I am being hired as a Probation Officer, Surveillance Officer or Probation Aide, access to a personal
vehicle is required for the accomplishment of assigned duties and responsibilities.
F.
If I am being hired as a Probation Officer, Surveillance Officer or Probation Aide, I must have, and
maintain a valid driver's license for the specific class of vehicle driven.
G.
I have discussed my job duties with my immediate supervisor and understand the duties that I will be
responsible to perform.
H.
If I am unable to report for work at the time instructed on the above specified date, I shall promptly notify
my immediate supervisor, and that in the absence of such notice, all commitments made herein may be
cancelled.
I.
If I am being hired as a Chief Probation Officer, Probation Officer or Surveillance Officer, I must meet
firearms certification requirements established by the Department of Corrections, and maintain such
certification as may be determined as applicable for sworn personnel.
J.
Other:
SIGNATURES:
Appointee
Field Operations Manager
August 2005
Date
Chief Probation Officer
Date
Date
PO/CO, Page 24
Name of Applicant
//
Date of Birth
AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES
I hereby request and authorize THE GEORGIA DEPARTMENT OF CORRECTIONS
Address of Local Hiring Authority
to obtain from:
Any Law Enforcement Agency, Former Employee or Personal Reference
Name of Person or Agency Holding the Information
The following type(s) of information from my records (and any specific portion thereof):
Criminal background check, character information from personal reference, and
Work record from former employers.
for the purpose of completing a Departmental Background Investigation for employment.
All information I hereby authorize to be obtained from this
person or agency will be held strictly confidential and
cannot be released again without my written consent.
Date
Signature of Applicant
Signature of Witness
Title or Relationship to Applicant
USE THIS SPACE IF APPLICANT WITHDRAWS CONSENT
Date this consent is revoked by applicant
Revised 10/10
Original
PO/CO, Page 25
STATE OF GEORGIA
LOYALTY OATH
STATE SECURITY QUESTIONNAIRE
NOTICE TO APPLICANTS/EMPLOYEES: The Sedition and Subversive Activities Act of 1953 (Ga. Laws, 1953), as amended, requires each
applicant/employee to complete and sign, prior to his/her employment in State government, a questionnaire which is designed to establish that there
are no reasonable grounds to believe that he/she is a subversive person. A subversive person is defined as one who commits acts, advocates, or
teaches the overthrow of the government of the United States or government of the State of Georgia by force or violence, or who is a knowing
member of a subversive organization. Georgia Code 45-3-11 requires all employees of State government to take an oath that they will support the
Constitution of the United States and the Constitution of the State of Georgia.
INSTRUCTIONS: All items must be completed on a typewriter or printed in ink. If more space is needed for any item, or explanation, continue under
item 10. This questionnaire and loyalty oath will be filed in the employee's personnel file in the employing agency. The employee may request that a
copy be executed for his/her personal files.
FULL NAME, INCLUDING MAIDEN NAME, NAMES OF FORMER MARRIAGES, FORMER NAMES CHANGED LEGALLY OR OTHERWISE,
ALIASES AND NICKNAMES AND THE DATES USED.
1. LAST NAME
FIRST NAME
PHONE NO.
MIDDLE NAME
MAIDEN NAME
DATES USED
NICKNAMES
DATES USED
OTHER NAMES, INCLUDING ALIASES &FORMER
DATES USED
NICKNAMES
DATES USED
DATES USED
NICKNAMES
DATES USED
MARRIAGES
2. ADDRESS
APT. NO.
3. DATE OF BIRTH
//
4.
CITY
STATE
COUNTY
RACE
U.S. CITIZEN
_____ Yes
______ No
ZIP
SEX
(Nationality _____________)
Are you now or have you been in the last ten (10) years a member of any organization which to your knowledge at the time of
membership advocates or has as one of its objects, the overthrow of the government of the United States or the government of the
State of Georgia by force or violence?
Yes
No
If "Yes", state the name of the organization and your past and present membership status including any offices held therein.
NOTE: If the answer to the above question is "Yes" and the employing authority deems further inquiry necessary, you will be notified of such
determination. No action adverse to your application will be taken because of an affirmative answer until after such an inquiry, with notice to you and
an opportunity for you to present evidence, and only if the results of such inquiry brings your application within the prohibition within the Sedition and
Subversive Activities Act of 1953.
5.
LIST CHRONOLOGICALLY ALL OF YOUR PREVIOUS RESIDENCES FOR THE PAST TEN YEARS:
DATES
From
6.
STREET
CITY
STATE
To
LIST NAMES AND ADDRESSES OF THE FOLLOWING:
SPOUSE
(MAIDEN NAME)
ADDRESS
FATHER
ADDRESS
MOTHER
ADDRESS
PO/CO, Page 26
7. MILITARY SERVICE: (Past or Present)
SERIAL
NUMBER
8.
BRANCH
ACTIVE SERVICE
From
To
DISCHARGED
Honorably
()
Dishonorably
()
Other
()
If Discharge other than
Honorable, explain in item 10.
Have you ever been convicted by Federal, State, or other law-enforcement authorities, for any violation of any Federal law, State law, county or municipal
law, regulation, or ordinance? (Do not include anything that happened before your sixteenth birthday. Do not include minor traffic violations for which a fine
of $35.00 or less was imposed.) _____YES ____NO
If answer is yes, provide the following information
CHARGE ON WHICH CONVICTED
DATE CONVICTED
Are you a former inmate, former parolee, or former probationer? _______YES _______NO
9.
ACTIVE OR INACTIVE
From
To
NAME OF COURT & PLACE WHERE CONVICTED
If answer is yes, provide dates and details.
Are there any charges now pending against you by Federal, State, or other law enforcement authorities for any violations of any Federal law, State law,
county or municipal law, regulation, or ordinance? (Do not include anything that happened before your sixteenth birthday.) Do not include minor violations
for which a fine of $35.00 or less would likely be imposed.) _____Yes _______ No If answer yes, provide dates and details.
VIOLATION CHARGED
NAME OF GOVERNMENT
Are you currently a parolee or probationer? ______YES _______NO
NAME OF COURT & LOCATION WHERE PENDING
If answer is yes, provide dates and details.
10. SPACE FOR CONTINUING ANSWERS OR EXPLANATIONS: (Show item numbers to which answers or explanation apply. Attach a separate sheet if
more space is needed.)
NOTE: Before signing this form, check all answers and explanations to see that you have answered all questions fully and correctly. This form
is to be executed under oath subject to the penalties of false swearing as prescribed in Code Section 16-10-71 of the Criminal Code of Georgia.
LOYALTY OATH
I,
, a citizen of
An employee of
United States of America
And being
And the recipient of public funds for services rendered as such employee, do hereby solemnly
swear and affirm that I will support the Constitution of the United States and the Constitution of the State of Georgia.
AFFIDAVIT OF VERIFICATION
Georgia
County
Personally appeared before the undersigned officer, duly authorized to administer
,who, after being duly sworn, deposes and says and declares under penalties
of false swearing that he is the person who executed the foregoing instrument; that he has read and completed the same and knows and understands the
contents thereof; that the matters stated therein and the answers and information furnished by him in the foregoing questionnaire, and loyalty oath, including
any attachments thereto, are true and correct.
SWORN TO AND SUBSCRIBED BEFORE ME:
This
(SIGNATURE OF AFFIANT)
Day of
, 20
(Notary Public)
PO/CO, Page 27
*F7$ERS*
Group Term Life Insurance Continuation While on Leave Without Pay Form
Information for this form may be typed directly onscreen before printing.
This form is not valid until received by ERSGA.
SECTION 1 - MEMBER INFORMATION
Retirement Plan Type
Last Name
SSN
First Name
Initial
Address
City
State
Zip Code
SECTION 2 - TERMS FOR CONTINUATION OF GTLI
I choose to continue Group Term Life Insurance (GTLI) coverage for any period during which I am on
Leave Without Pay (LWOP). I understand that the following conditions apply:
•
I must have one (1) year of continuous service before I can continue my GTLI coverage
while on LWOP.
•
Premiums of one percent (1%) of the monthly salary immediately prior to my period of
LWOP will accrue for each month I am on LWOP.
•
The accrued premiums will be paid to the Employees' Retirement System as follows:
•
At termination of state employment and on application for a refund of my contributions
and interest, the premiums will be deducted from my refund;
•
Or, at my retirement, the premiums will be deducted from my monthly benefit;
•
Or, at my death, the premiums will be deducted from the GTLI payment to my beneficiaries.
NOTE: If I have eighteen years of creditable service and terminate state employment and do
not get a refund of my contributions and interest, GTLI coverage will continue until the ERS
receives my written notification declining coverage. Any premiums accrued up until that time
will be payable to the ERS by the applicable method described above.
SECTION 3 - SIGNATURE & ACKNOWLEDGEMENT
I have read and I understand the instructions and provisions listed above.
SIgnature
Date
Two Northside 75 Suite 300 • Atlanta, GA 30318-7701 • PHONE (404) 350-6300 (800) 805-4609 • FAX (404) 350-6308 • www.ersga.org
PO/CO, Page 28
VH54--0008
Attachment 1
09/01/01
TUBERCULOSIS SCREENING OF CORRECTIONAL PERSONNEL
ACKNOWLEDGEMENT STATEMENT
This is to acknowledge that I have read the Department's procedure governing tuberculosis screening of correctional
personnel. As a condition of employment, I will abide by the terms and conditions of this procedure. I understand that
any violation of this procedure, including any of the standards contained therein, may be the basis for disciplinary
action, including dismissal.
Employee Signature
Employee’s Printed Name
Date Signed
Employee’s ID#:
PO/CO, Page 29
TRANSFER UNDERSTANDING MEMORANDUM
My signature on this memorandum indicates my understanding that as a new appointee, I will
work at
for a period of not less than twelve (12) months prior to being eligible for transfer to another facility. In
addition, any request for transfer will contain a 30 day notice prior to effective date of transfer.
Employee Signature
Date
Witness
PO/CO, Page 30
300 Patrol Road
Forsyth, Georgia 31029
MEMORANDUM TO PERSONNEL FILE
This is to certify that I have been given information about the State Board of Workers' Compensation, the
"Panel of Physicians" and the purpose of these services.
I understand that if I am involved in an on-the-job accident and become ill or injured, if emergency treatment
is NOT necessary, I must accept all medical services from a Panel physician. If I obtain medical service from
a physician who is not listed with the AMERISYS, INC. managed care organization, I will be responsible for
those medical expenses.
The AMERISYS, INC. (Panel) Physician may arrange for appropriate consultations, referrals or other specialized
medical services as the nature of the injury requires. If I am dissatisfied with the medical services, I can request one
change (without the employer's permission) to visit a second (different) physician from the AMERISYS, INC. group.
However, any further changes require the expressed permission of a Claim Representative from the Department of
Administrative Services, or the State Board of Workers' Compensation.
In the case of an emergency, I may be treated at the nearest emergency room. However, all follow-up
care must, thereafter, be rendered by a physician designated/selected from the managed care
organization (or a AMERISYS, INC. referral).
I further understand that I must notify my supervisor and the Personnel Office as soon as injury occurs or as soon as I
receive care from AMERISYS, INC., regardless of the extent of the injury. [Delay in notification can result in denial of
payment for medical services rendered].
If my claim is accepted as compensable and I am entitled to receive weekly indemnity benefits (if I have more than
seven days of lost time from work, due to the injury), I understand that I am entitled to ONE independent medical
examination by a physician of my choice. However, I must notify DOAS in writing, in advance of any independent
examination. The cost will be paid by DOAS but no diagnostic procedures performed since the date of my on-the-job
injury (and costing in excess of $250.00), can be repeated by my independent physician. I understand that I may be
expected to pay for procedures which have not been authorized by DOAS.
DATE
SIGNATURE OF EMPLOYEE
Equal Opportunity Employer
PO/CO, Page 31
*F8$ERS*
Election/Declination of Membership
For Those First Employed On or After Age 60
Name_________________________________
(Please Print)
________________________
//
_____/______/_____*
Date of Birth (m/d/yr)
O.C.G.A 47-2-72 states that any person who first becomes an employee eligible for retirement system
coverage at age 60 or later may elect NOT to become a member of the Employees’ Retirement System under
provision of O.C.G.A. 47-2-350 (Georgia State Employees’ Pension and Savings Plan - GSEPS). Such
election must be made in writing to the ERS Board of Trustees by completion and submission of this for to
the Employees' Retirement System within 30 days of hire and is irrevocable.
Based on the foregoing, this is to provide notice to the Board of Trustees of the Employees' Retirement
System that I hereby: (check one)
__________
Elect Membership with Employees' Retirement System and based on this election, I
understand that I will establish membership under the GSEPS benefit structure. I
understand that my decision is final and cannot be changed in the future.
___________
Decline Membership with the Employees' Retirement System. I understand that by electing
non-membership I am forfeiting any rights under the ERS. I further understand that my
decision is final and cannot be changed in the future.
*You must provide proof of age (copy of birth certificate, driver’s license, passport, etc.) along with this form.
________________________________
____________________________
Employee Signature
Date
Return this signed form to the Employees' Retirement System of Georgia within 30 days of hire. Mail to
the following address:
Employees' Retirement System
Two Northside 75, Suite 300
Atlanta, GA 30318
For questions, contact ERS at 1-800-805-4609 or, in Metro Atlanta, 404-350-6300.
F8 ERS Revised 01/2009
Page 1 of 1
PO/CO, Page 32
*G1$ERS*
Membership Election Form for Vested Members of the
Employees' Retirement System or Teachers Retirement System
Member Name________________________________________
(Please Print)
______________________________
Dept./School_______________________________ Dept./School ID_____________________________
O.C.G.A 47-2-181(c)(1-4) and O.C.G.A 47-3-81(b)(1-5) state that any vested member (10 or more years of
creditable service excluding forfeited leave) of the Employees' Retirement System (ERS) or the Teachers
Retirement System (TRS) who becomes an employee in an agency covered by the other System may elect to
remain a member of their vested System. This election must be made in writing to the Boards of Trustees
not later than 60 days of first becoming employed in a position covered by the other System and is
irrevocable.
To the Boards of Trustees of the ERS and TRS:
Being vested, I elect to remain a member of the (check one):
Teachers Retirement System
Member Signature:_____________________________________
Date:_______/_______/__________
OR
I elect to become a member of the (check one):
Teachers Retirement System
Member Signature:_____________________________________
MEMBER:
Date:_______/_______/__________
Upon completion, file a copy of this form with your Human Resources or Payroll office.
EMPLOYER: Send a copy of the completed, signed form to the Employees' Retirement System and
Teachers Retirement System within 60 days of hire.
G1ERS Revised 03/2009
Page 1 of 1
PO/CO, Page 33
SOP IVO07-0024
Attachment 1
Revised 10-10
EMPLOYEE'S DESIGNATION OF BENEFICIARY
To Receive Any Outstanding Wages or Other Monies Upon the Employee's Death
In the event of my death, I authorize any wages or other monies due me from the Georgia Department of
Corrections to be paid to the following beneficiary:
FIRST BENEFICIARY___________________________________________________________________________________________
Address:________________________________________________________________________________________________
Street
(P.O.Box or Apt #)
City
State
Zip Code
Relationship:__________________________________Date of Birth: _______________________________________________
Month
Day
Year
Social Security Number:_______________________________________
_____________________________ (If first
SECOND BENEFICIARY
beneficiary is deceased)
Address:________________________________________________________________________________________________
Street
(P.O.Box or Apt #)
City
State
Zip Code
Month
Day
Year
_____________________________ (If first and
THIRD BENEFICIARY
second beneficiaries are deceased)
Address:________________________________________________________________________________________________
Street
(P.O.Box or Apt #)
City
State
Zip Code
Month
Day
Year
Employee Name: ____________________________________________________________________________
(Print Full Name)
Employee ID #:__________________________________
I understand that it is my responsibility to ensure that this information is current and up-to-date.
Employee SIGNATURE: _______________________________________ DATE: ______________________
Record Retention: Retain permanently in the official personnel file.
PO/CO, Page 34
GSEPS 401(k) Plan
Opt-Out Form
Complete this form to Opt Out of (decline participation in) the GSEPS 401(k) Plan.
Please print or type clearly.
SECTION 1: Participant Information
Date of Birth
//
Your Name
Agency Name
Your Hire Date
Mailing Address: Street/P.O. Box
City
State
Zip Code
An important note about GSEPS and qualified default investment alternatives (QDIA)
As a new state of Georgia employee hired on or after January 1, 2009, if you do not choose to decline participation in the
GSEPS 401(k) Plan by completing of this form, you are Automatically enrolled in the GSEPS 401(k) Plan using the Peach
State Reserves 401(k) Plan, and contributions of one percent (1%) of your salary will be taken beginning with your first
paycheck. An employer matching contribution of 1% will also be contributed to your account. You may choose to contribute
more, and receive additional matching contributions. Review the matching information in the GSEPS Plan Brochure or at the
Employees' Retirement System of Georgia website at www.ersga.org. Your contributions will be invested in the Plan’s
QDIA—an investment alternative or option as defined under rules issued by the Department of Labor chosen by the Plan’s
fiduciary for those instances when participants fail to provide instruction on how to invest monies in their 401(k) retirement
plan account.
The QDIA for the GSEPS 401(k) Plan is the appropriate Lifecycle Fund, based on your age and expected date of retirement. A
description of the Lifecycle Funds is available at http://myGApsr.ingplans.com or by calling ING at 1-866-694-2777. This
description includes information on the objective of the investment, as well as risk and return characteristics, related fees and
expenses, and any restrictions on your ability to transfer or direct your money out of the investment.
SECTION 2: Opt-Out Instructions
 You can choose not to be Automatically enrolled in the GSEPS 401(k) Plan by declining participation if you
complete this form and return to your Payroll or Human Resources office. You must submit this form within five (5)
business days from your date of hire, or you will be Automatically enrolled and contributions will be deducted from your
salary. You may also subsequently choose to stop participation by contacting ING at 1-866-694-2777 or online at
http://myGApsr.ingplans.com. If you are Auto-enrolled, you have a right to a Ninety (90) calendar day period from date of
hire during which a refund of contributions (plus or minus any gains or losses) can be requested.

If you choose to decline participation upon hire by completing this Opt-Out Form, you may later enroll at any time in the
GSEPS 401(k) plan by subsequently contacting ING at 1-866-694-2777 or online at http://myGApsr.ingplans.com. Note
that if you decline Auto-Enrollment upon hire by signing this form, you forfeit the right to a Ninety (90) calendar day
period from date of hire during which a refund of contributions (plus or minus any gains or losses) can be requested.
SECTION 3: Member Acknowledgement and Signature
I have read the information provided above and understand by signing this form, I hereby confirm my election to NOT
participate in the GSEPS 401(k) Plan.
Employee Signature:_______________________________________________________Date:_________________________
Return this signed form to your Human Resources office within 3 days of hire if
Opting Out of (declining participation in) the GSEPS 401(k) Plan. You may enroll in
the future by contacting ING directly (see Section 2 above)
PO/CO, Page 35
Direct Deposit Notification Form
(To be signed by all new hires and rehires on and after May 1, 2010)
In accordance with the Mandatory Direct Deposit policy issued May 1, 2010, as a condition of
employment, a person hired or rehired to a position in a State organization on or after May 1, 2010, and
who is paid by the PeopleSoft HCM central payroll system (system) administered by the State
Accounting Office (SAO), is required to accept all payroll related payments by direct deposit. The
complete policy, and related documents, can be found on SAO’s website at the following location:
State Accounting Office Accounting Policy Manual.
I understand that as a condition of employment, because I am a new hire or rehire applicant, I must comply with the
policy and enroll in direct deposit using the Employee Self Service (ESS) feature of the system within 30 days
of being hired or rehired and remain enrolled in direct deposit during the tenure of my employment. I understand
that I can apply for an exemption from this requirement as provided by the policy. I understand that if I am not
granted an exemption, I may be subject to dismissal.
Employee Name (Please Print) _______________________________________________________
Employee Signature: ______________________________________________ Date: ____________
To be completed by employing organization:
Employee ID Number: ___________________ Position Title: ______________________________
Hiring Organization Name: __________________________________________________________
Hiring Supervisor or HR Official: _____________________________________________________
Copy 1 – Organization Human Resources Office
Copy 2 – Employee
Direct Deposit Notification Form
(To be signed by all new hires and rehires on and after May 1, 2010)
In accordance with the Mandatory Direct Deposit policy issued May 1, 2010, as a condition of
employment, a person hired or rehired to a position in a State organization on or after May 1, 2010, and
who is paid by the PeopleSoft HCM central payroll system (system) administered by the State
Accounting Office (SAO), is required to accept all payroll related payments by direct deposit. The
complete policy, and related documents, can be found on SAO’s website at the following location:
State Accounting Office Accounting Policy Manual.
I understand that as a condition of employment, because I am a new hire or rehire applicant, I must comply with the
policy and enroll in direct deposit using the Employee Self Service (ESS) feature of the system within 30 days
of being hired or rehired and remain enrolled in direct deposit during the tenure of my employment. I understand
that I can apply for an exemption from this requirement as provided by the policy. I understand that if I am not
granted an exemption, I may be subject to dismissal.
Employee Name (Please Print) _______________________________________________________
Employee Signature: ______________________________________________ Date: ____________
To be completed by employing organization:
Employee ID Number: ___________________ Position Title: ______________________________
Hiring Organization Name: __________________________________________________________
Hiring Supervisor or HR Official: _____________________________________________________
Copy 1 – Organization Human Resources Office
Copy 2 – Employee
Submit executed forms to:
State Accounting Office
Fax Number: 770-359-5944
Email: [email protected]
Direct Deposit Personal Exemption Request Form
Employee Information
Last
First
Street Address
City
M
State
Zip Code
Job Title
Employee ID
Organization / Department
Business Unit
Employee’s Email Address
Work Phone
Policy
It is the policy of the State of Georgia that all employees paid by the PeopleSoft HCM central payroll system (system) administered by
the State Accounting Office (SAO) be required to use direct deposit to receive payroll related payments. The policy can be found on
SAO’s website at the following location: State Accounting Office Accounting Policy Manual.
Personal Exemption Request (To be completed by employee desiring to be exempted from the requirement that they enroll in direct deposit)
I request that I be paid by paper check for the following reason (check one):
I currently do not have an account at an eligible financial institution and am unable to obtain an account. Attached is
a letter from an eligible financial institution to this effect.
I request that the State Accounting Officer consider an exemption for my specific extreme hardship. Attached is a
letter explaining my hardship.
Employee Acknowledgements
All payroll related payments will be made in accordance with OCGA 50-5B-3(3) which states “The State Accounting Officer shall
prescribe the manner in which disbursements shall be made by state government organizations.” For payroll related payments not made
by electronic funds transfer, all paper checks will be mailed by the State Accounting Office on the employee’s designated payday and will be
dated the date of the employee’s pay date. No post dated paper checks will be mailed prior to the designated payday. Any employee receiving
his/her pay by paper check will be required to maintain a valid mailing address in the system.
The State assumes no responsibility for the delay in receiving a paper check via the United States mail or its equivalent. Should a paper
check have to be reissued due to a lost check, the employee may have to wait up to seven days before a replacement check can be issued
and mailed.
Employee may enroll in direct deposit should circumstances change. Employee acknowledges that he/she may be offered other payment
methods as options, other than paper check, when such options may become available.
By signing below, I acknowledge having been provided a copy of the referenced policy requiring direct deposit, acknowledge the
advisement to hires and rehires regarding possible dismissal, acknowledge the risks associated with paper checks, and hereby submit
my request for exemption for the reason stated above.
________________________________________________________ _____________________________
Date
Criminal/Driver History Consent Form
I hereby authorize the Georgia Department of Corrections to receive all criminal history record information
pertaining to me which may be in the files of any criminal justice agency on the National Crime Information
Center/Georgia Crime Information Center (NCIC/GCIC) network anytime during the course of my employment with
the Department. I understand that convictions revealed from these background investigations may impact my
certification with POST and my employment with the department.
I do solemnly state that the below listed information is true and correct to the best of my knowledge and belief.
Social Security #
Last First Middle Maiden (please print)
Street Address
City
State
Zip
Driver's License #
County
//
Date of Birth
Height
Sex
Weight
Race
Eye Color
Hair Color
Skin Tone
Scars, Marks, Tattoos
Birthplace (City and State)
Signature
Home:
Date
Work: ____________________
Phone number where you can be reached
between the hours of 8:00 am and 4:00pm
Notary
PO/CO, Page 37
PRE-EMPLOYMENT DRUG TESTING ACKNOWLEDGEMENT STATEMENT
I, _____________________________ acknowledge that I have read and understand the following stipulations required by
State Law.
I understand that, as a condition of employment with the Department of Corrections I must take and pass a drug test. The
test is conducted under the authority of O.C.G.A. 45-20-110 to determine the presence of illegal drugs.
I am willing to take the drug test as directed, and I understand that the cost of this drug test will be paid by the employer.
I understand that if I refuse to take the drug test or fail to appear at the testing location by the specified date, I will be
disqualified from employment with any State employer for a period of two (2) years.
I understand that should my drug test results indicate the presence of illegal drugs and such presence is not found by the
Medical Review Officer to be authorized by state or federal law, I will be disqualified from any employment with any State
employer for a period of two (2) years from the date that the test was administered.
I acknowledge that I have taken or have been asked to take a drug test for the following State employers within the last
two years (includes any agency, department, commission, bureau, board, college, university, institution, or authority):
State Employer
Date of Test
I certify that the results for each test showed no presence of illegal drugs.
I acknowledge that withholding or falsifying any of the requested information will result in immediate
termination of my employment with the Department of Corrections.
I understand that if I refuse to sign this form I am forfeiting any further consideration for this position with the
Department of Corrections.
My signature below acknowledges that I am aware that this statement will become a part of my
official personnel record.
Print Applicant's Name
Signature
Date
Pre drug (Rev. 10-10)
PO/CO, Page 38
INSTRUCTIONS FOR COMPLETING FORM G-4
Enter your full name, address and social security number in boxes 1a through 2b.
Line 3: Write the number of allowances you are claiming in the brackets beside your marital status.
A. Single - enter 1 if you are claiming yourself
B. Married Filing Joint, both spouses working - enter 1 if you claim yourself or 2 if you claim yourself and
your spouse
C. Married Filing Joint, one spouse working - enter 1 if you claim yourself or 2 if you claim yourself and
your spouse
D. Married Filing Separate - enter 1 if you claim yourself or 2 if you claim yourself and your spouse
E. Head of Household - enter 1 if you claim yourself but the individual(s) for whom you maintain a home
does not qualify as a dependent; or 2 if you claim yourself and a qualified dependent for whom you
maintain a home
Do not claim a deduction on Line 4 for a dependent used to qualify you as head of household
Line 4: Enter the number of dependent allowances you are entitled to claim.
Line 5: Complete the worksheet on Form G-4 if you claim additional allowances. Enter the number
from Line H here.
Failure to complete and submit the worksheet will result in automatic denial of your claim.
Line 6: Enter a specific dollar amount that you authorize your employer to withhold in addition to the tax
withheld based on your marital status and number of allowances.
Line 7: Enter the letter of your marital status from Line 3. Enter total of the numbers on Lines 3 - 5.
Line 8: Check the box if you qualify to claim exempt from withholding. You can claim exempt if you filed a
Georgia income tax return last year and the amount on Line 4 of Form 500EZ or Line 16 of Form 500
was zero, and you expect to file a Georgia tax return this year and will not have a tax liability. You can
not claim exempt if you did not file a Georgia income tax return for the previous tax year. Receiving a
refund for the previous tax year does not qualify you to claim exempt.
Do not complete Lines 3 - 7 if claiming exempt.
EXAMPLES: Your employer withheld $500 of Georgia income tax from your wages. The amount
on Line 4 of Form 500EZ or Line 16 of Form 500 was $100. Your tax liability is
the amount on Line 4 or Line 16; therefore, you do not qualify to claim exempt.
Your employer withheld $500 of Georgia income tax from your wages. The amount
on Line 4 of Form 500EZ or Line 16 of Form 500 was $0 (zero) and you filed a
prior year income tax return. Your tax liability is the amount on Line 4 or Line 16;
therefore, you qualify to claim exempt.
NOTE: Effective January 1, 2003, the deduction allowed for the dependents increased from $2,700 to
$3,000. This does not apply to the deduction allowed for you or your spouse.
O.C.G.A. § 48-7-102 requires you to complete and submit Form G-4 to your employer in order to have tax withheld
from your wages. By correctly completing this form, you can adjust the amount of tax withheld to meet your tax
liability. Failure to submit a properly completed Form G-4 will result in your employer withholding tax as though
you are single with zero allowances.
Employers are required to mail any Form G-4 claiming more than 14 allowances or exempt from withholding to
the Georgia Department of Revenue for approval. Employers will honor the properly completed form as submitted
pending notification from the Withholding Tax Unit. Upon approval, such forms remain in effect until changed or
until February 15 of the following year. Employers who know that a G-4 is erroneous should not honor the form
and should withhold as if the employee is single claiming zero allowances until a corrected form has been received.
PO/CO, Page 38a
Form G-4 (Rev. 10/06)
STATE OF GEORGIA
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
1a. YOUR FULL NAME
1b. YOUR SOCIAL SECURITY NUMBER
2a. HOME ADDRESS (Number, Street, or Rural Route)
2b. CITY, STATE AND ZIP CODE
READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM
3. MARITAL STATUS (If you do not wish to claim an allowance, enter “0” in the brackets beside your marital status.)
A. Single: enter 0 or 1 ................................... [
]
B. Married Filing Joint, both ...........................
spouses working: enter 0 or 1 or 2 ............ [
]
C. Married Filing Joint, one ............................
spouse working: enter 0 or 1 or 2 .............. [
]
D. Married Filing Separate:
enter 0 or 1 or 2 ........................................ [
]
E. Head of Household: ..................................
enter 0 or 1 or 2 ........................................ [
]
4. DEPENDENT ALLOWANCES [ ]
5. ADDITIONAL ALLOWANCES
[ ]
(complete worksheet below)
6. ADDITIONAL WITHHOLDING $
WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES
This worksheet must be completed if Line 5 is greater than zero.
1. COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION:
Yourself:
Age 65 or over
Blind
Spouse:
Age 65 or over
Blind
Number of boxes checked
x 1300 = $
2. ADDITIONAL ALLOWANCES FOR DEDUCTIONS:
A. Estimated Federal Itemized Deductions ................................................................ $
B. Georgia Standard Deduction (enter one): Single/Head of Household $2,300
Each Spouse
$1,500 $
C.
D.
E.
F.
G.
H.
Subtract Line B from Line A ................................................................................................... $
Allowable Deductions to Federal Adjusted Gross Income ...................................................... $
Add the Amounts on Lines 1, 2C, and 2D .............................................................................. $
Estimate of Taxable Income not Subject to Withholding......................................................... $
Subtract Line F from Line E (if zero or less, stop here) .......................................................... $
Divide the Amount on Line G by $3,000. Enter total here and on Line 5 above ......................
This is the maximum number of additional allowances you can claim. If the remainder is over $1,500 round up.
7. LETTER USED (Marital Status A, B, C, D, or E )
TOTAL ALLOWANCES (Total of Lines 3 - 5)
(Employer: The letter indicates the tax tables in the Employer’s Tax Guide)
8. EXEMPT: Skip this line if you entered information on Lines 3 - 7. Read the instructions for Line 8 on page 2.
I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have
a Georgia income tax liability this year. Check here
I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemption from withholding status
claimed on this Form G-4. Also, I authorize my employer to deduct per pay period the additional amount listed above.
Employee’s Signature
Date
Employer: Complete Line 9 and mail entire form only if the employee claims over 14 allowances or exempt from withholding.
If necessary, mail form to: Georgia Department of Revenue, Withholding Tax Unit, P. O. Box 49432, Atlanta, GA 30359.
9. EMPLOYER’S NAME AND ADDRESS:
EMPLOYER’S FEIN:
EMPLOYER’S WH#:
Do not accept forms claiming additional allowances unless the worksheet has been completed. Do not accept forms
claiming exempt if numbers are written on Lines 3 - 7.
PO/CO, Page 39
Form W-4 (2010)
Page
2
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
2
3
4
5
6
7
8
9
10
Enter an estimate of your 2010 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions
1
$11,400 if married filing jointly or qualifying widow(er)
Enter:
$8,400 if head of household
2
$5,700 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter “-0-”
3
Enter an estimate of your 2010 adjustments to income and any additional standard deduction. (Pub. 919)
4
Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 6 in Pub. 919.)
5
Enter an estimate of your 2010 nonwage income (such as dividends or interest)
6
Subtract line 6 from line 5. If zero or less, enter “-0-”
7
Divide the amount on line 7 by $3,650 and enter the result here. Drop any fraction
8
Enter the number from the Personal Allowances Worksheet, line H, page 1
9
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10
兵
其
$
$
$
$
$
$
$
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3.”
1
2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to figure the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet
4
5
Enter the number from line 1 of this worksheet
Subtract line 5 from line 4
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
Divide line 8 by the number of pay periods remaining in 2010. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2009. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
$0
7,001
10,001
16,001
22,001
27,001
35,001
44,001
50,001
55,001
65,001
72,001
85,001
105,001
115,001
130,001
- $7,000 - 10,000 - 16,000 - 22,000 - 27,000 - 35,000 - 44,000 - 50,000 - 55,000 - 65,000 - 72,000 - 85,000 -105,000 -115,000 -130,000 - and over
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
$0
6,001
12,001
19,001
26,001
35,001
50,001
65,001
80,001
90,001
120,001
6
7
8
- $6,000
- 12,000
- 19,000
- 26,000
- 35,000
- 50,000
- 65,000
- 80,000
- 90,000
-120,000
and over
-
All Others
Married Filing Jointly
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code
sections 3402(f)(2) and 6109 and their regulations require you to provide this
information; your employer uses it to determine your federal income tax withholding.
Failure to provide a properly completed form will result in your being treated as a single
person who claims no withholding allowances; providing fraudulent information may
subject you to penalties. Routine uses of this information include giving it to the
Department of Justice for civil and criminal litigation, to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in administering their tax
laws, and using it in the National Directory of New Hires. We may also disclose this
information to other countries under a tax treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism.
If wages from HIGHEST
paying job are—
$0
65,001
120,001
185,001
330,001
- $65,000
- 120,000
- 185,000
- 330,000
and over
If wages from HIGHEST
Enter on
line 7 above paying job are—
$550
910
1,020
1,200
1,280
$0
35,001
90,001
165,001
370,001
- $35,000
- 90,000
- 165,000
- 370,000
and over
Enter on
line 7 above
$550
910
1,020
1,200
1,280
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
PO/CO, Page 39a
Form W-4 (2010)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Consider completing a new
Form W-4 each year and when your personal or
financial situation changes.
Exemption from withholding. If you are
exempt, complete only lines 1, 2, 3, 4, and 7
and sign the form to validate it. Your exemption
for 2010 expires February 16, 2011. See
Pub. 505, Tax Withholding and Estimated Tax.
Note. You cannot claim exemption from
withholding if (a) your income exceeds $950
and includes more than $300 of unearned
income (for example, interest and dividends)
and (b) another person can claim you as a
dependent on his or her tax return.
Basic instructions. If you are not exempt,
complete the Personal Allowances Worksheet
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized
deductions, certain credits, adjustments to
income, or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
payments using Form 1040-ES, Estimated Tax
for Individuals. Otherwise, you may owe
additional tax. If you have pension or annuity
income, see Pub. 919 to find out if you should
adjust your withholding on Form W-4 or W-4P.
Head of household. Generally, you may claim
head of household filing status on your tax
return only if you are unmarried and pay more
than 50% of the costs of keeping up a home
for yourself and your dependent(s) or other
qualifying individuals. See Pub. 501,
Exemptions, Standard Deduction, and Filing
Information, for information.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure
the total number of allowances you are entitled
to claim on all jobs using worksheets from only
one Form W-4. Your withholding usually will
be most accurate when all allowances are
claimed on the Form W-4 for the highest
paying job and zero allowances are claimed on
the others. See Pub. 919 for details.
Tax credits. You can take projected tax
credits into account in figuring your allowable
number of withholding allowances. Credits for
child or dependent care expenses and the
child tax credit may be claimed using the
Personal Allowances Worksheet below. See
Pub. 919, How Do I Adjust My Tax
Withholding, for information on converting
your other credits into withholding allowances.
Nonwage income. If you have a large amount
of nonwage income, such as interest or
dividends, consider making estimated tax
Nonresident alien. If you are a nonresident
alien, see Notice 1392, Supplemental Form
W-4 Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2010. See Pub.
919, especially if your earnings exceed
$130,000 (Single) or $180,000 (Married).
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent
● You are single and have only one job; or
B Enter “1” if:
● You are married, have only one job, and your spouse does not work; or
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
兵
A
其
B
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
C
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.)
D
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return
E
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
F
F Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
● If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
● If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
G
child plus “1” additional if you have six or more eligible children.
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) 䊳 H
● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
worksheets
$18,000 ($32,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
兵
Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
5
6
7
OMB No. 1545-0074
Employee’s Withholding Allowance Certificate
2010
䊳
Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Type or print your first name and middle initial.
Last name
2
Your social security number
Home address (number and street or rural route)
3
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. 䊳
Married, but withhold at higher Single rate.
Single
Married
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
5
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
6
Additional amount, if any, you want withheld from each paycheck
I claim exemption from withholding for 2010, and I certify that I meet both of the following conditions for exemption.
● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
䊳
If you meet both conditions, write “Exempt” here
7
$
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(Form is not valid unless you sign it.)
8
䊳
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date
9 Office code (optional) 10
Cat. No. 10220Q
䊳
Employer identification number (EIN)
Form
W-4
(2010)
PO/CO, Page 40
Personal Information Form
Education, Language and Military
PRINT NAME: ___________________________
EMPLID:____________________
Highest Education Level
(Check only 1 box)
B- Less Than HS Graduate
C- HS Graduate or Equivalent
D- Some College
E- Technical School
F- 2-Year College Degree
G- Bachelor’s Level Degree

H- Some Graduate School
I- Master’s Level Degree
J- Doctorate (Academic)
K- Doctorate (Professional)
L- Post-Doctorate

Language Code
(Check only if fluent in a language OTHER than English. Check only 1)

Can French
Danish
Dutch
French
German
Greek
Intl Eng
Italian
Japanese
Korean
Portuguese
SChinese
Spanish
Swedish
TChinese
Thai

Military
(Check only 1 –Most recent status recommended.)
Active Reserve
Inactive Reserve
Not a Veteran
Post-Vietnam-Era Veteran

Pre-Vietnam-Era Veteran
Retired Military
Vietnam-Era Veteran

Any questions should be directed to your local Personnel Representative.
_______________________________________________
Signature/Date
PO/CO, Page 41
Revised 10-10
CRISIS CARD
Hire Date:
Location:
Last Name
First Name
Employee ID Number
Middle Name
Position Number
//
Title
Birth Date
Complete Home Address
Home Telephone Number
Blood Type
Next of Kin
Address
Revised 10/10
Relationship
City
Phone Number
State
Zip
PO/CO Page 42, Local 1
EMERGENCY CONTACT(S)
Employee ID #_________________
Employee Name_________________________________
PRIMARY CONTACT
Contact Name:
Relationship to Employee:
Home Address and Telephone (Same Address/Home Phone as Employee)
Address 1:
Address 2:
Address 3:
City:
County:
State:
Zip:
Phone Number:
Additional Phones
Phone Type: (Circle One)
Business
Cellular
Pager
Fax
Business
Cellular
Pager
Fax
Yes
No
(Circle One)
Yes
No
(Circle One)
Yes
No
(Circle One)
Number:
Number:
ADDITIONAL CONTACT
Contact Name:
Address 1:
Address 2:
Address 3:
City:
County:
State:
Zip:
Phone Number:
Additional Phones
Business
Cellular
Pager
Fax
Business
Cellular
Pager
Fax
Number:
Number:
ADDITIONAL CONTACT
Contact Name:
Address 1:
Address 2:
Address 3:
City:
County:
State:
Zip:
Phone Number:
Additional Phones
Business
Cellular
Business Cellular
Pager
Pager
Fax
Fax
Number:
Number:
SOP IVO15-0005
Attachment 1
Revised 10-10
REQUEST FOR IDENTIFICATION CARD
NAME
EMPLOYEE ID/SCRIBE ID (REQUIRED)
EMPLOYEE JOB TITLE
FACILITY/UNIT OF ASSIGNMENT
DIVISION
CONTRACTOR OR ORGANIZATION REPRESENTING
TYPE OF IDENTIFICATION CARD
(check applicable lines)
DO YOU HAVE AN I.D. CARD TO TURN IN?
EMPLOYEE
YES
NO
LOCATOR
VOLUNTEER
LOST/STOLEN
CONTRACTOR
CARD TYPE
POSITION TITLE
(division or section):
IDENTIFICATION CARD WILL NOT BE ISSUED IF EMPLOYEE/SCRIBE I.D. NUMBER
AND/OR APPOINTING AUTHORITY APPROVAL IS OMITTED
APPOINTING AUTHORITY/DESIGNEE APPROVAL:
PRINT NAME:
Date:
FACILITY/UNIT:
TITLE:
(FOR PERSONNEL OFFICE USE ONLY)
IDENTIFICATION CARD ISSUANCE
CARD TYPE ISSUED (circle all types issued):
EMP
LOC
CON
EXPIRATION DATE:
VOL
(Signature)
(Imaging Site)
IDENTIFICATION CARD ISSUANCE TO CARD HOLDER
CARD HOLDER ACKNOWLEDGES RECEIPT OF
(Signature)
Retention Schedule:
(Check applicable line)
EMPLOYEE I.D.
VOLUNTEER I.D.
CONTRACTOR I.D.
LOCATOR CARD
(Date)
Retain permanently in local file (official personnel file if made in CPA); copy retained for two (2) years at imaging site for any
employee from a non-imaging site.
MILITARY SERVICE INFORMATION
Name:
Employee ID:
Branch of Service (Select one):
Air Force Reserve
Army Reserve
Reserves (this page)
Coast Guard Reserve
Marine Corps Reserve
Navy Reserve
National Guard (next page)
Air National Guard
Army National Guard
Reserve Unit Number and Name (Select one):
AIR FORCE RESERVE
4 March ARB
78 Security Forces Squadron
94 Airlift Wing
179 Air Defense Artillery Btry
226 Combat HQ
301 Fighter Wing
302 Airlift Wing
315 Airlift Wing
315 Mission Support
340 Flying Training Group
349 Air Mobility Wing
403 Wing
434 Air Refueling Wing
439 Airlift Wing
440 Airlift Wing
445 Airlift Wing
446 Airlift Wing
482 Fighter Wing
512 Airlift Wing
514 Air Mobility Wing
610 SFS
622 RSC Combat Logistics Supp Sqd
622 ASTS
908 Airlift Wing
910 Airlift Wing
911 Airlift Wing
913 Airlift Wing
914 Airlift Wing
917 Wing
919 Special Operations Wing
920 Rescue Wing
926 Fighter Wing
931 Air Refueling Group
932 Airlift Wing
934 Airlift Wing
939 Rescue Wing
944 Fighter Wing
ARMY RESERVE
0003 Army
2 Medical Brigade
3 Medical Cmd
3 Pers Cmd
8 Medical Brigade
9 Reg Support Cmd
63 Reg Readiness Cmd
65 Reg Supp Cmd
70 Reg Supp Cmd
81 Reg Support Cmd
87 (TS)
94 Reg Supp Cmd
96 Reg Supp Cmd
162 Combat Cmd
165 Security Police Squadron
167 Infantry Bn
175 CS Co
191 Maintenance Co
220 Military Police Brigade
300 Military Police Cmd (EPW)
310 Chemical Co
311 Theater Signal Cmd
330 Medical Brigade
333 Medical Co.
335 Theater Signal Cmd
341 AG Postal Co
345 Regiment Battalion
347 Regiment Battalion
351 Military Police Co
352 Support Battalion
359 Signal Brigade
366 Chemical Co (SG)
375 Transportation Grp
376 Transportation Grp
377 QM PS Co
411 Quartermaster Co
412 Engineer Cmd
416 Engineer Cmd
420 Engineer Brigade
Page 1 of 2
ARMY RESERVE (cont’d)
421 QM Co (Light Airdrop Supply)
461 AG Battalion
800 Military Police Brigade (EPW)
802 Quartermaster Platoon
803 Quartermaster Co
804 Medical Brigade
807 Medical Brigade
841 Engineer Battalion
988 Quartermaster
1014 QM Co
1015 Maintenance Company
1188 USA Trans Terminal Battalion
2125 Garrison Support
2145 Military Police
3397 Garrison Support
Aug 10/168 (PN/HS) 5 Bd
Company 452d MP Det
Medical Brigade – HHD 5 Bde (HS)
COAST GUARD RESERVE
Coast Guard – ANTTEAM
MARINE CORPS RESERVE
4th Force Svcs Support Grp
4th LAAD
HMLA 773
MAG 42
MALS 42
MARFORRES 4th Div
VMFA 142
NAVY RESERVE
84089 Forced Protection SW-Det A
Comcar Air Wing Res20
EOD Mobile Unit 12
NAS Atlanta
NCW Group II
NMCRC Atlanta
NMCRC Augusta
NMCRC (Fla.)
NRC Columbus
VAW-77
VFA-203
VR-46
Return this page if the employee is a member of the Reserves and their unit is listed above. Do not return page 2.
Revised 10/10
MILITARY SERVICE INFORMATION
Name:
Employee ID:
National Guard – State (Select One):
Georgia
Florida
South Carolina
Alabama
North Carolina
Other (write name):
National Guard Unit (Select One):
AIR NATIONAL GUARD
116 Air Control Wing
117 Air Control Squadron
165 Airlift Wing
165 Security Forces Squadron AMC
202 Eng Installation Squadron
224 Joint Comm Spt Squadron
283 Combat Comm Squadron
Combat Readiness Training Center
Townsend Bombing Range
ARMY NATIONAL GUARD
3 Infantry Detachment
48 Infantry Brigade
75 Engineer Detachment
78 Troop Cmd
93 Sig Bde
94 Aerial Port Squadron (AFRC)
108 Calvary
108 Armor Regiment (AR)
110 Corp Support Battalion
116 Army Band
117 Field Artillery
118 Field Artillery
121 Infantry Battalion
122 Infantry Reg
124 Mobile Public Affairs Det
ARMY NATIONAL GUARD (cont’d)
126 Aviation Support Regt
131 Aviation Support Regt
141 Support Battalion
148 Support Battalion HSB
149 Armor Brgd, 35 Infantry (Ala.)
158 Maint Co, Det 1 (Ala.)
161 MED
165 QM Co (POL)
171 Aviation Regt
181 Field Artillery
188 Field Artillery
196 Field Artillery Brgd
202 Ord Det. (EOD)
214 Field Artillery
214 Military Police Co (Ala.)
221 Military Intelligence BN
239 Transportation Co
248 Military Intelligence CO
251 Rear Area Ops Ctr (S.C.)
264 Engr Det
265 Engr Gp
267 NRCUSE
269 Eng Co (Const Supp) Florida
ARMY NATIONAL GUARD (cont’d)
277 Maintenance Co
324 Sig Battalion
377 OM PS Co
429 Medical Evac Battalion
587 Service Co
648 Combat Eng
718 Engineer Co
731 Ordnance Det (MLRS) (Tenn.)
802 Ordinance Co
878 Engineer Combat Battalion
1128 Trans Company (Alabama)
1207 US Army Hospital
2025 TC Co. Alabama
AASF #1, Winder
AASF #2, Dobbins
AASF #3, Savannah
HD STARC
HQ 1203 Engr Bn (Topo) (Ala.)
Medical Detachment
Op Spt Airlift Cmd
Recon & Air Int Det (RAID)
If your unit is not listed, complete this section:
Branch of Service (Select one):
Air Force Reserve
Coast Guard Reserve
Army Reserve
Marine Corps Reserve
Navy Reserve
Air National Guard
Army National Guard
Unit Number and Name:
Page 2 of 2
Return this page if the employee is a member of the National Guard or their unit is not listed. Do not return page 1.
Revised 10/10
Pg __
Of __
Initial
____
CERTIFICATION OF CANDIDATE – PAGE 1
Projected Academy:
Projected Academy Start Date
Candidate’s Last Name
Candidate’s Position
(Select One)
Candidate’s First Name
Corrections Ofc
Candidate’s Middle Name
Probation Ofc
Give suffix (such as Jr. , Sr., II, III, IV, V, etc.) :
Maiden Name
Date of Employment
RACE
(mm/dd/yyyy)
SEX/GENDER
Education (select highest level that documentation is provided for in this application)
Social Sec#
Date of Birth
(mm/dd/yyyy)
WEIGHT
HEIGHT
HAIR
COLOR
lbs
//
EYE
COLOR
Are you a citizen of the United States?
Yes
No
AGENCY MAKING APPLICATION
AGENCY PHONE#
(AREA CODE) - NUMBER
(
NAME OF AGENCY CONTACT (Agency Person Processing Application)
)-
-
CONTACT PHONE#
(
)-
-
EXT
@
The above listed candidate is/will be employed with your agency as which of the following:
Full time Corrections Officer
Full time Probation Officer
(Note: Full-time employment is a minimum of 30 hours/week or 120 hours/28 day period.)
Checklist (Please check each block below to verify that a complete application is provided.)
___
___
___
___
___
___
___
___
___
Page 2 Agreement/Photo
Page 3 PH Release
Page 4 Verification
Page 5 Birth/Citizen
___
___
___
___
Page 6 Education
Page 7 Military
Page 8 Entrance Exam/LE Hist
Page 9 Driver Hist
Birth Certificate or other docs provided
Naturalization Papers. (both must be attached.)
___
Notarized/Written Statement required (see Appendix 9)
High School Diploma/GED/Homeschool Affidavit
Electronic Fingerprint Submission Results attached
Fingerprint Cards mailed
___
___
___
___
___
___
___
___
___
Page 10 Criminal History
Page 11 Printout/FPs
Page 12 Attestation
Physician’s Affidavit
DD214 form
Discharge explanation
Entrance Exam Results
GCIC/NCIC Printout
Driver’s History
Pg __
Of __
Initial
____
CANDIDATE AGREEMENT & PHOTOGRAPH – PAGE 2
Please read and sign in the presence of the agency head or authorized representative
acknowledging your acceptance and understanding of this agreement.
I,
(FULL NAME OF CANDIDATE – First Middle Last),
when approved for Basic Correctional Officer or Probation Officer Academy Training,
agree to obey all rules and regulations, and understand that I am subject to dismissal
from the Training Academy for any infractions or failure to achieve the scholastic
standard set by the Georgia POST Council. I further certify that I am in good health,
physically fit, and of good moral character and release the Georgia Peace Officer
Standards and Training Council, the Department of Public Safety, the Georgia Public
Safety Training Center, the State of Georgia, and any other official associated or
connected with the training academy for liability in case of illness or accident.
I understand that I must satisfactorily complete a basic training course prior to
performing the duties of a peace officer, according to O.C.G.A. §35-8-9.
This application will be valid for 18 months only. If not certified by that time, a new
application must be submitted according to POST Council Rule 464-3-.01.
Place
Photograph
Here
________________________________________
Candidate Signature
Date
________________________________________
Agency Head or Authorized Representative Signature
Pg __
Of __
Initial
____
PERSONAL HISTORY RELEASE – PAGE 3
I do hereby authorize the review of and full disclosure of all records concerning myself
to the duly authorized agent of the Georgia Peace Officer Standards and Training
Council.
The intent of this authorization is to give my consent for full and complete disclosure of
the records of educational institutions; the records of the U.S. Department of Defense
including any military records; 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 examinations or reports, efficiency
ratings, complaints or grievances filed by or against me and the records and
recollections of attorneys at law, or of other counsel, whether representing me or
another person in any case, either criminal or civil, in which I presently have or have
had an interest.
I understand that any information obtained by a personal history background
investigation, which is developed directly or indirectly, in whole or part, upon this release
authorization will be considered in compiling any report for the Georgia Peace Officer
Standards and Training Council. I 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 photo copy of this release form will be valid as an original thereof, even though the
said photocopy does not contain an original writing of my signature.
I understand that this information may be obtained through the use of this waiver at any
time during which my registration or certification is maintained through the Georgia
Peace Officer Standards and Training Council.
Last Name
DATE OF BIRTH
First Name
Middle Name
MAIDEN NAME
PHONE NUMBER
(mdyyyy)
//
(
)-
-
Email Address
@
ADDRESS: Street
City:
Apartment/Unit#
State:
-
Zip Code:
____________________________________________
_________________
____________________________________________
_________________
Candidate Signature (including maiden name)
Notary Public Signature
Date
Date
Pg __
Of __
Initial
____
VERIFICATION/RECOMMENDATION/ACKNOWLEDGEMENT – PAGE 4
I have verified the information provided by the candidate contained in this application, and I am aware
that it is my responsibility to provide POST with a complete and accurate application on behalf of my
agency. My initials have been placed in the upper right hand corner on each page to signify my
review of the information provided, and I accept responsibility for the veracity of this application.
Based on my verification, this candidate has met the requirements of O.C.G.A. § 35-8-8.
_________________________________________________
Signature –Agency Employee Responsible for Verification
_______________________
Date
BACKGROUND INVESTIGATION
(FULL NAME OF CANDIDATE – FIRST, MIDDLE INITIAL, LAST)
Date Candidate was interviewed:
Name of Interviewer (First Last)
(mm/dd/yyyy)
The Background Investigator verified the following information with the appropriate authorities:
- Education (High School & College)
Yes
No
- Prior LE Employment & Certification
Yes
No
Not applicable
- Military
Yes
No
Not applicable
- Criminal History
Yes
No
- Traffic History
Yes
No
Name of Background Investigator (First Last)
Date Background Investigation Completed
(mm/dd/yyyy)
__________________________________________________________________________________
Signature of Person Conducting Background Investigation
AGENCY HEAD RECOMMENDATION
The candidate named in this application was found to satisfy the requirements of O.C.G.A. § 358-8, and is recommended by me for attendance to a Basic Law Enforcement Training Course
and for certification upon successfully completing this training. I am aware of POST
reimbursement guidelines and understand that the candidate must be a paid, full-time employee
during training to receive reimbursement.
(NOTE: Once this application is approved a POSTFORM #2 authorizing the academy/school
attendance will be issued. No person shall perform the duties of a peace officer until successful
completion of the Basic Law Enforcement Training Course.)
“(a) No person required to comply with the certification provisions of this chapter shall be
employed or appointed by any law enforcement unit without certification from the Council that
the applicant has met the pre-employment requirements established in this chapter.”
__________________________________________
Agency Head Signature
_______________________
Date
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BIRTH & CITIZENSHIP VERIFICATION – PAGE 5
Does candidate’s name match the name on their birth certificate?
Yes
No
If No, please list all of the names that candidate has had since birth and explain discrepancy (adoption,
marriage, name change, etc).
(Documentation for a name change for anything other than marriage MUST be attached.)
Check here if name change documentation is attached
Names: (List chronologically with most recent first):
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Explanation(s) for name changes:
Was Candidate born in the United States?
Yes
No
Country of birth if other than U.S.:
City:
State:
Was the candidate a U.S. military dependent at the time of birth?
Is the candidate a naturalized citizen?
Yes
Yes
No
No
NOTE: If naturalized, a certified copy of the naturalization papers OR a copy of their U.S. passport must be submitted.
ATTACHMENTS
Attached to this page is a copy of the candidate’s certified birth certificate:
If NO, attached is a copy of the candidate’s valid Georgia Driver’s License
and:
(must have at least one of the following documents – check the ones that are attached)
YES
NO
Baptismal Record (w/full name & date of birth)
Draft Card (w/full name & date of birth)
Court Records (w/full name & date of birth)
Passport (w/full name & date of birth)
Citizenship Papers (w/full name & date of birth)
Armed Forces Discharge Paper (DD214) (w/full name & date of birth)
Certified Copy of School Records (w/full name & date of birth)
IMPORTANT NOTE:If any of the above documents are used for this verification, the documents must show the
full name and date of birth of the candidate. In order to establish the place of birth, the candidate must submit
a signed & notarized statement (Appendix 9) indicating that the candidate is a United States citizen if
documents other than a birth certificate are furnished . Included in this statement must be the place, date and
country of birth.
If the candidate is a naturalized citizen, a certified copy of the naturalization papers or a copy of their U.S.
passport and a completed Appendix 9 must be submitted.
Appendix 9 attached (Appendix 9 is the required signed & notarized statement listed above)
Certified copy of naturalization papers or U.S. passport is attached
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EDUCATION – PAGE 6
Please attach High School Diploma or GED or Home School Affidavit to this page.
Candidate graduated high school from:(select one)
(Important Note: School must have a state, regional, or national accreditation that POST accepts – see www.chea.org for acceptable
accrediting agencies.)
High School Name:
Location of High School (City/State):
Year Graduated (yyyy)
H.S. Phone #
(
)-
-
COLLEGE
Candidate received their highest college degree from:
Year Graduated w/highest degree (yyyy)
The degree was a/an:
Note: If candidate wishes to have their college degree recorded in their profile, a copy of their diploma or a certified copy of their
college/university transcript can be attached in addition to their high school diploma.
Check here if candidate has ALSO attached a college diploma/transcript for their profile.
List colleges/universities attended or obtained a degree from (list colleges/universities):
(Use and attach appendix 4 for additional degrees obtained and/or colleges attended)
College/Univ:
Attended from (mo/yr to mo/yr):
to
Did not obtain degree
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
* IMPORTANT NOTE: If the candidate obtained their diploma from a correspondence school or received a
diploma via the internet, the hiring agency will need to check & attach accreditation of the school. Schools
issuing diplomas must be accredited by one of the POST accepted accrediting agencies (see www.chea.org for
acceptable accrediting agencies).
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MILITARY – PAGE 7
PLEASE ATTACH YOUR MILITARY DISCHARGE OR DD214 HERE.
(DD214 (Member 4 form version) must indicate type of discharge.)
Did this candidate serve in the military?
Yes
No
(If “NO”, go to the next page. If Yes, complete this page.)
Candidate served in the (check as apply):
Navy
National Guard
Air Force
Army
Coast Guard
Marines
Reserves – Give Branch
Other Department of Defense service – list
IMPORTANT NOTE: If the candidate recently served or is currently serving in the reserves, it is acceptable to
attach a letter from their current military reserve commander regarding their service record.
Candidate’s dates of enlistment:
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
Was candidate’s CHARACTER OF SERVICE/DISCHARGE honorable?
Yes
No
(If Yes, go to the next page. If No, candidate’s character of service was listed as (choose applicable one from
pull down menu below):
Honorable
A brief explanation regarding candidate’s character of service/discharge must also be attached to
this page (providing details for the reason for this character).
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ENTRANCE EXAM & LE EMPLOYMENT HISTORY – PAGE 8
ENTRANCE EXAM (POST FORM EE) is attached to this page.
LAW ENFORCEMENT CERTIFICATION HISTORY
1. Has the candidate ever been certified or previously submitted an application to GA Post Council?
Yes
No
2. Has the candidate ever been certified as an officer in another state?
(If YES, list state & certification #’s. Use appendix 6 for additional listings if necessary.)
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
Yes
No
If the candidate answers “YES” to #2 above, POST requires written proof from the other state’s POST Council or equivalent that the officer’s
certification in that state is in “good standing.” See Reference Manual for more details on “Good Standing”. (Check box below to verify that
proof of good standing is attached.)
3. Has the candidate ever been denied an application for certification for a law enforcement
professional position (i.e. police, jail, communications, probation, parole, etc) in GA or another state?
Yes
No
N/A If YES, a written signed explanation must be provided. Check box below if attached.)
4. Has the candidate’s certification ever been disciplined or sanctioned in another state?
YES
NO
N/A (If YES, provide a written signed explanation & check box below if attached.)
Attachments to this page:
Proof of Officer’s “good standing’/certification status (needed for states other than Georgia ONLY)
A written & signed explanation of the officer’s denial.
A written & signed explanation of the officer’s discipline or sanction.
LAW ENFORCEMENT EMPLOYMENT HISTORY
Please list law enforcement agencies that you have worked for in chronological order (with most recent first). See appendix 6
for additional pages for employment history if necessary.
Agency Name:
State:
Employed from (mo/yr)
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
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Certified Driver History – PAGE 9
Attached is a certified copy of candidate’s GA driver’s history or printed from GCIC
Attached is a certified copy of candidate’s driver’s history from another state
IMPORTANT NOTE:
Certified copy of an individual’s driver’s history must be the approved/accepted version by the state’s
department that governs driver’s licenses and driver histories.
Candidate has possessed driver’s licenses in what states in the past 10 years: (Check what applies)
Georgia Driver’s License ONLY during past 10 years
Military Driver’s License ONLY during past 10 years
Military Driver’s License (From (yr)
To (yr)
)
States other than Georgia (list years and states below)
YEARS:
From (yr)
To (yr)
State:
From (yr)
To (yr)
State:
From (yr)
To (yr)
State:
From (yr)
To (yr)
State:
From (yr)
To (yr)
State:
From (yr)
To (yr)
State:
Has candidate ever been given a traffic citation?
Yes (If Yes, complete this section.)
No (If No, go to next page.)
Has candidate received more than three citations during the past five years?
Has candidate ever had their license suspended?
Year:
DUI/DWI
Points
Yes
No
Yes (If yes, check which reason and give year)
Insurance related
Other
No
If other, give brief reason below:
Reason:
List any traffic citation received during the past five years. Use Appendix 2 if necessary.
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
Information verified by Candidate: _______________________________________________________
Candidate’s Signature
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CRIMINAL HISTORY – PAGE 10
Please read the following information carefully before completing the next pages.
Pursuant to Title 35, Chapter 8 of the Official Code of Georgia Annotated and the Rules of the Georgia Peace
Officer Standards and Training council, each applicant is required to disclose EACH AND EVERY arrest and/or
citation which the applicant has received, along with the disposition of EACH AND EVERY arrest and/or citation.
Dispositions include, but are not limited to, dismissal, placement on a dead docket, nolle prosequi, finding or
verdict of guilty or not guilty, plea of guilty, plea of nolo contendere, treatment under the First Offender Act,
expungement, sealed, pardoned, or bond forfeiture. NOTE: Failure to provide all requested information
(including any intentional or unintentional omissions) may result in the rejection/denial of the application.
Has the candidate lived only in the state of Georgia:
Has the candidate ever been arrested?
Yes
No
Yes If Yes, complete this section.
Has the candidate ever been convicted of a felony?
Yes
No If No, go to the Next Section.
No
Has candidate ever been charged with a crime of domestic/ family violence?
Yes
No
(If YES, a copy of the police incident report and the court disposition regarding the arrest must be attached.)
Is the candidate currently or ever been subject to a qualifying protection order (temporary or federal) prohibiting
the possession of a firearm or ammunition?
Yes
No (If Yes, submit copy of the order.)
List all felonies first. List all other charges in chronological order (with most recent first). Use Appendix 1 if necessary.
DATE OF
ARREST
m/d/yyyy
ARRESTING AGENCY
CONVICTED:
Yes
No
CHARGE (pick from list, if not on list provide below)
Check all that apply:
Fine
If not on list, give charge:
Amount:
DISPOSITION:
Time(mos/yrs):
Probation
Incarceration
Time(mos/yrs):
If OTHER, give disposition below:
DATE OF
ARREST
m/d/yyyy
Community Service
ARRESTING AGENCY
CONVICTED:
Yes
No
Fine
Amount:
DISPOSITION:
Time(mos/yrs):
Probation
Incarceration
Time(mos/yrs):
Attachments:
Police Incident Report
Community Service
Court Disposition
Signed/Notarized Statement re: incident
Information verified by Candidate: _______________________________________________________
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GCIC/NCIC PRINTOUT/FINGERPRINT RESULTS - PAGE 11
State law requires a fingerprint check to be conducted by both GCIC and NCIC for candidates for certification.
Agencies have three (3) options for meeting this requirement. Check option your agency has chosen below:
OPTION 1: (Recommended) Attached Electronic Fingerprint Results for GCIC/NCIC
(Both GCIC & NCIC results required.)
See Georgia Applicant Processing Service at web site (http://www.ga.cogentid.com/index.htm)
for fingerprinting service or go to a local law enforcement agency that has an electronic
fingerprinting system such as LIVESCAN.) See Appendix 13 for more details.
IMPORTANT NOTE:
If the agency attaches both GCIC and NCIC electronic fingerprint results, then a printout from the GCIC and NCIC
criminal history is not required..
OPTION 2: Attached original & complete printout of GCIC/NCIC criminal history & agency has
submitted fingerprint cards to GCIC for processing
For Department of Corrections: Two (2) fingerprint cards sent to GDC Personnel in Atlanta.
OPTION 3: Attached GCIC “processed” card result & NCIC “processed” card result
- GCIC processed fingerprint cards have the results from GCIC noted on the card.
- FBI/NCIC result will be the Civil Applicant Response and Rap Sheet if applicable.
IMPORTANT NOTE:
It is strongly recommended that an agency use an electronic fingerprint submission for processing prints (either
Georgia Applicant Processing Service at web site (http://www.ga.cogentid.com/index.htm) or a local law
enforcement agency’s electronic fingerprinting system). Agencies that do not have access to such systems are
encouraged to check with larger agencies in their area to see if one is available. By attaching these electronic
fingerprint submission results, agencies are able to improve the efficiency of the certification process.
Please do not send “unprocessed” fingerprint cards with this application. Doing so significantly slows down the
process of certification.
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CANDIDATE ATTESTATION – PAGE 12
I have personally reviewed this application regarding ALL INFORMATION provided by me including my
criminal and driver history. I attest and affirm that the information provided in this application including my
criminal and traffic history is complete and correct to the best of my knowledge. I further understand that
any act of omission may be grounds for denial of this application for certification as a peace officer
(O.C.G.A. §35-8-7.1) and could result in criminal prosecution (O.C.G.A. §16-10-20). Each page is signed
by me confirming verification of the data on that individual page. I understand that any page not signed
and verified by me could result in a delay of processing of this application.
Last Name
Social Sec#
First Name
Date of Birth
(mm/dd/yyyy)
Middle Name
Suffix:
//
________________________________________________
________________
Applicant Signature (Sign Full Name)
Date
AGENCY ATTESTATION
As the agency head (or designee for the agency head), I have reviewed this application regarding ALL
INFORMATION provided by the candidate including the criminal and driver history. I attest and affirm that
the information provided in this application including the criminal and traffic history are within the hiring
standards of our department and adhere to the requirements set forth by the Georgia Peace Officer
Standards Training Council.
Print Name of Agency Head (or designee)
________________________________________________
________________
Agency Head (or designee) Signature
Date
_______________________________________________
________________
Notary Public
Date
Notary Seal
Here
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Physician’s Affidavit – PAGE 1 of 3
PHYSICIAN’S INSTRUCTIONS:
Please complete this form and answer all questions related to your medical examination of this candidate. Do
the following steps:
1. Review the candidate’s job duties/responsibilities for which he/she is being employed to
make sure that you are familiar with the relevant job demands and working conditions of the
specific position for which the candidate is being considered. Additional information such as job
descriptions; critical knowledge, skills, or tasks lists; or other items may be provided. A list of job
duties and responsibilities should be provided to you by the hiring agency along with this form.
2. Complete the patient information at the bottom of this page and then conduct your physical
exam.
3. Review the patient’s Medical and Physical History. A Report Form may be provided to you
by the candidate or you may use the form commonly used in your medical practice.
4. Answer all questions by checking the appropriate block on each page and providing any
comments necessary for the hiring agency’s assessment.
5. SIGN & DATE on the appropriate page of this form and provide your address & phone #.
(Please note that this exam must be conducted by a licensed physician or osteopath, and the
form signed by a licensed physician or osteopath only. (Forms signed by other personnel such
as nurses, nurse practitioners, physician’s assistant, or other staff will be rejected.)
6. Give all forms to the candidate for return to the hiring agency.
This candidate, if certified, will have the prerequisites necessary to gain employment at any law enforcement
agency in the State of Georgia, including but not limited to the current place of employment. Peace officers are
charged with the responsibility of enforcing criminal laws and are subject to deal with violent individuals and
situations. Officers are often required to defend themselves and others from physical attacks, subdue resisting
individuals, and make decisions under stress concerning the use of deadly force. These types of positions
generally require a high level of physical capability.
O.C.G.A. §35-8-8 and POST Rule 464-3-.02 require that candidates be found, after examination by a licensed
physician or surgeon, to be free from any physical, emotional, or mental conditions which might adversely affect
his/her exercising the powers or duties of a peace officer. Please note that your answers are intended to
provide the hiring agency with the most useful information possible to base an employment decision, confirm to
the Georgia Peace Officer Standards and Training Council that this candidate meets the requirements set forth
in POST Rule 464-3-.02, and in your medical opinion, this candidate is capable of safely completing the
required training and safely performing the necessary job duties.
Name of Agency Contact (Agency Person Processing Application)
Contact Phone#
(Area Code) - Number
( )-
-
EXT
@
SECTION 1: TO BE COMPLETED BY LICENSED EXAMINING PHYSICIAN
Social Sec#
Last Name
DATE OF BIRTH
Suffi
x:
(mm/dd/yyyy)
Maiden Name
//
Job Applied for by the candidate is:
First Name
HEIGHT
ft
in
Middle Name
WEIGHT
lbs
(without shoes
& coat)
SEX:
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Physician’s Affidavit - PAGE 2 of 3
1.) In your opinion, does the candidate have, or is the candidate likely to develop, any physical
symptoms or limitations that could impair performance in this position?
No
Indeterminate
Yes
 Job functions affected

Nature & degree of severity

Duration of impairment (if intermittent or temporary)

Likelihood(s) associated with this impact
2.) In your opinion, could the candidate’s performance in this position result in a risk to the health and
safety of the candidate or others?
No
Indeterminate
Yes
 Specific job duties/functions and/or working conditions that precipitate the risk:

Nature & severity of potential harm:

Impact of harm on self and/or others:

Likelihood(s) associated with this risk:

Imminence and duration of the threat;
Please describe any means, devices or work restrictions that could reduce or eliminate any identified risks to a
level not significantly greater than that posed by the average candidate. Include the manner in which the
accommodation needs to be implemented, maintained, and monitored; any side effects or risks associated with
the accommodation; and a revised estimate of the candidate’s viability in this position if it is implemented.
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Physician’s Affidavit - Page 3 of 3
3.) In summary, what is your overall evaluation of the candidate’s ability to safely perform the duties of
this position? (choose one below)
This candidate has no physical, emotional, or mental conditions that might adversely affect his/her
ability to perform the duties of a peace officer or take part in training programs relative to law
enforcement.
Comments:
This candidate has no physical conditions that might adversely affect his/her ability, but there are
some concerns that should be addressed regarding one or more emotional or mental conditions that
could adversely affect their ability. (Please state recommendations on how to address here.)
Comments:
This candidate has no emotional or mental conditions that could adversely affect their ability, but
there are some concerns that should addressed regarding one or more physical conditions that could
adversely affect their ability. (Please state recommendations on how to address here.)
Comments:
This candidate has one or more physical , emotional, or mental conditions that could adversely
affect their ability that need to be addressed. (Please state recommendations on how to address here.)
Comments:
SIGNATURE OF LICENSED
EXAMINING PHYSICIAN (required)
EXAMINING PHYSICIAN’S NAME (printed)
DATE (m/d/yyyy)
____________________________________________________
Last
First
ADDRESS OF LICENSED EXAMINING PHYSICIAN’S PRACTICE
________________________________________________________________________
Street
Phone:
Area Code+Number
(
)
________________________________________________________________________
City, State, Zip
SECTION 2: HIRING AUTHORITY’S ASSESSMENT
(TO BE COMPLETED BY HIRING AUTHORITY)
Based on the information provided by the physician and the candidate, it is my belief that the candidate meets
the state standards for this position and can safely perform the essential job demands of the position for which
they are being hired. If a reasonable accommodation is necessary for this individual and the state standards
are still met, I have attached a letter explaining the necessary accommodations.
SIGNATURE OF AGENCY HEAD OR DESIGNEE (required)
Accommodation Noted:. Check here if a letter from agency head giving details of
accommodation is attached (required). This letter indicates that the candidate
needs a reasonable accommodation which can be implemented without undue
hardship to the agency & still meets state standards.
DATE
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APPENDIX 1 – ADDITIONAL CRIMINAL HISTORY
List all felonies first. List all other charges in chronological order (with most recent first).
DATE OF
ARREST
m/d/yyyy
ARRESTING AGENCY
CONVICTED:
Yes
No
Fine
Amount:
DISPOSITION:
Time(mos/yrs):
Probation
Incarceration
Time(mos/yrs):
DATE OF
ARREST
m/d/yyyy
Community Service
ARRESTING AGENCY
CONVICTED:
Yes
No
Fine
Amount:
Probation
Time(mos/yrs):
Incarceration
DISPOSITION:
Time(mos/yrs):
Community Service
DATE OF
ARREST
m/d/yyyy
ARRESTING AGENCY
CONVICTED:
Yes
No
Fine
Amount:
Probation
Time(mos/yrs):
Incarceration
DISPOSITION:
Time(mos/yrs):
Community Service
Attachments:
Police Incident Report
Court Disposition
Signed/Notarized Statement re: incident
Information verified by Candidate:_______________________________________________________
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APPENDIX 2 – ADDITIONAL DRIVER HISTORY
List any traffic citation received during the past five years.
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
DATE OF
CITATION
TRAFFIC VIOLATION
ISSUING AGENCY
DISPOSITION
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APPENDIX 3 – ADDITIONAL NAMES
Names: (List chronologically with most recent first):
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Name:
Used from (YR)
to (YR)
Explanation(s) for name changes:
Information verified by Candidate: ______________________________________________________
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APPENDIX 4 – ADDITIONAL EDUCATION
List colleges/universities attended or obtained a degree from (list colleges/universities):
(Use and attach appendix 4 for additional degrees obtained and/or colleges attended)
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
College/Univ:
to
Obtained:
Associate’s
Bachelor’s
Master’s
Doctorate
degree.
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APPENDIX 5 – ADDITIONAL MILITARY
Navy
National Guard
Air Force
Army
Coast Guard
Marines
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
Yes
No
Honorable
Navy
National Guard
Air Force
Army
Coast Guard
Marines
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
Yes
No
Honorable
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APPENDIX 6 – ADDITIONAL L.E. HISTORY
Additional certifications:
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
STATE (Ex. GA):
CERTIFICATION#
Please list law enforcement agencies that you have worked for in chronological order (with most recent first). See
appendix 6 for additional pages for employment history if necessary.
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Agency Name:
State:
to:
Position held:
Reason for leaving:
Pg __
Of __
Initial
____
APPENDIX 9 – CITIZENSHIP VERIFICATION STATEMENT
I,
(FULL NAME OF CANDIDATE – First Middle Last) ,
(Name of City, State,
Terrority/Country of Birth)
do hereby state that I was born in
,
,
.
on (date of birth)
My parents names are (father)
and (mother)
.
I became a U.S. Citizen by (check one):
Birth within the territory of the United States.
My parents are United States citizens.
Naturalization - I became a United States naturalized citizen on (date)
(Please note that a copy of their U.S. naturalization certificate or their U.S. passport must be
included with this application.)
____________________________________________
_________________
____________________________________________
_________________
Candidate Signature (including maiden name)
Notary Public Signature
Notary Seal
Here
Date
Date
Pg __
Of __
Initial
____
APPENDIX 10
AFFIDAVIT OF SUCCESSFUL COMPLETION OF HOME STUDY
PROGRAM FROM PARENT/GUARDIAN
Last Name
Social Sec#
First Name
Date of Birth
(mm/dd/yyyy)
Middle Name
Suffix:
Section I
ATTESTATION OF APPLICANT
I,
(FULL NAME OF CANDIDATE – First Middle Last) hereby swear or affirm, under criminal penalty of a felony
subject to punishment by fine of not more than $ 1000.00 or by imprisonment for not less than one nor
more than five years, that I received the attached home study diploma pursuant to my successful
completion of a home study program as recognized by applicable Georgia Law.
_________________________________
_____________________________________________________________________
Signature of Notary Public
Date
Notary Seal
Section II
ATTESTATION OF PARENT / GUARDIAN
I, (FULL NAME OF Parent/Guardian– First Middle Last)
,hereby swear or affirm, under criminal penalty of a
felony subject to punishment by fine of not more than $ 1000.00 or by imprisonment for not less than one
nor more than five years, that , my child / ward, received the attached home study diploma pursuant to
his/her successful completion of a home study program as recognized by applicable Georgia Law. I
further swear or affirm that the home study program completed by my child / ward was administered by a
person or persons duly qualified to administer such a program under applicable Georgia Law.
_________________________________
_____________________________________________________________________
Date POST-FORM - ED1
Date
Notary Seal
Pg __
Of __
Initial
____
APPENDIX 11
AFFIDAVIT OF SUCCESSFUL COMPLETION OF HOME STUDY
PROGRAM FROM PARENT/GUARDIAN (Parent/Guardian Deceased)
Last Name
Social Sec#
First Name
Date of Birth
(mm/dd/yyyy)
Middle Name
Suffix:
Section I
ATTESTATION OF APPLICANT
I,
(FULL NAME OF CANDIDATE – First Middle Last) hereby swear or affirm, under criminal penalty of a felony
subject to punishment by fine of not more than $ 1000.00 or by imprisonment for not less than one nor
more than five years, that I received the attached home study diploma pursuant to my successful
completion of a home study program as recognized by applicable Georgia Law.
_________________________________
_____________________________________________________________________
Date
Notary Seal
Section II
ATTESTATION OF PARENT / GUARDIAN DEATH
I,
(FULL NAME OF CANDIDATE – First Middle Last),
hereby swear or affirm, under criminal penalty of a felony
subject to punishment by fine of not more than $ 1000.00 or by imprisonment for not less than
one nor more than five years, that my parent (s) / guardian having custody of me during my
home study program died on
(mm/dd/year).
_________________________________
_____________________________________________________________________
Date
Notary Seal

Georgia Department of Corrections Employee Hiring

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