EFTA00035605.pdf

BP-A0203
JUN 10
FEDERAL PRISON SYSTEM PRETRIAL INMATE WORK
WAIVER/NOTICE OF SEPARATION
U.S. DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
CDFRM

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 The waiver may be rescinded at the inmate's request and reasons for the rescission should be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 understand that it is possible that I will have contact with inmates already convicted of a crime. I
am / am not (circle one) aware of any reason why my having contact with convicted prisoners
would pose a threat to my safety or the safety of others.
[Signature]
Inmate Signature
76318-054
Reg. No.
7.8.19
Date
[Redacted]
Staff Signature/Title

B. Inmate Refuses to Sign
Date
Staff Signature/Title

REASONS STATED (IF ANY):
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EFTA00035605

III. POLICY
Bureau 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
Date

IV. WORK WAIVER
I have read 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 a person not
convicted of a crime I may not be required to work.
[Signature]
Inmate Signature
76318-054
Reg. No.
7.8.19
Date
[Redacted]
Staff Signature/Title

V. REVOCATION OF WAIVER
I hereby rescind the work waiver previously claimed above:
Inmate Signature
Reg. No.
Date
Staff Signature/Title

STAFF COMMENTS:

WDP
Prescribed by P7331
Replaces BP-203(73) OF APR 80 and BP-S203(73) of May 94
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EFTA00035606