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

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 The waiver may be rescinded at the inmate’s request and reasons for the rescission should be documented in Section V of this form and signed by a staff member.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.

B. [Signature]
Inmate Signature

76318-054
Reg. No.

7.8.19
Date

[Redacted Signature (b)(6); (b)(7)(C)]
Staff Signature/Title

B. Inmate Refuses to Sign

Date

Staff Signature/Title

REASONS STATED (IF ANY ):

1

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