— _— . BP-A0203 FEDERAL PRISON SYSTEM PRETRIAL INMATE WORK core JUN 10 WAIVER/NOTICE OF SEPARATION U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS pe einen I. INSTRUCTIONS The staff member conducting intake screening shall advise the pretrial inmate, depending upon the design, structure, and operation of the individual institution, that the inmate may have contact with convicted inmates. The inmate is to be asked to sign the appropriate portion in Section II of this Pretrial Inmate Work Waiver/Notice of Separation. If the inmate refuses to sign this segment of the form, staff shall document this refusal on the form. A pretrial inmate who wishes to waive the exemption from work must sign the appropriate portion in Section IV of this Pretrial Inmate Work Waiver/Notice of Separation. This form must be completed prior to the issuance of a work assignment. If the inmate’s behavior suggests an inability to comprehend the waiver, or if the inmate has been admitted to a mental health referral for evaluation or treatment, the inmate must be referred to a mental health professional for an assessment as to competency to sign the waiver. The waiver may be rescinded at the inmate’s request and reasons for the rescission should be documented in Section V of this form and signed by a staff member. The waiver shall be maintained in the inmate’s unit file or record office file and will remain in the file as a permanent document. The inmate may be given a copy of this form if the inmate so requests. II. NOTICE OF SEPARATION A. I undeggtand that it is possible that I will have contact with inmates already convicted of 2 crime. I am/ fia nop) circle one) aware of any reason why my having contact with convicted prisoners would pose a thr fety or the safety of others. —WSiwosy = 7.8.19 Reg. No. © Date Staff Signature/Title B. Inmate Refuses to Sign Date Staff Signature/Title REASONS STATED (IF ANY ): EFTA00035605

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Ill, POLICY Buresu of Prisons policy states a pretrial inmate may not be compelled to work other than to perform housekeeping tasks in the inmate’s own cell and in the community living area. FOR STAFF USE. ONLY I am referring this inmate to the institution’s psychologist/psychiatrist because: ____ The inmate’s behavior suggests the inmate may not be able to comprehend this waiver. The inmate has been admitted for mental evaluation or treatment. Staff Signature/Printed Name/Title IV. WORK WAIVER I heveresd-or had read to me the policy provisions in Section II of this form and would like to volunteer for a work assignment which entails more than housekeeping tasks. I understand that as 2 person not convicted of a crime I may not be required to work. Wsleoy PIF Inmate Signature Reg. No. Date - Staff Signature/Title V. REVOCATION OF WAIVER I hereby rescind the work waiver previously claimed above: i Inmate Signature Reg. No. Date Staff Signature/Title STAFF COMMENTS: wpP Prescribed by P7331 Replaces BP-203(73) OF APR 80 and BP-S203(73) of May 94 EFTA00035606