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Maintain Highest Level of Security Practices

Definition

Sound security policies provide standardized procedures for a variety of security systems that, when properly utilized, are designed to minimize vulnerabilities in the workplace.  Maintaining the highest level of these practices in a Correctional Industries (CI) setting helps to create an environment that safeguards the life, health, and personal safety of staff, incarcerated Individuals and the public while at the same time providing the necessary education, work, and rehabilitative opportunities that enable an incarcerated Individual to be productive while incarcerated and prepare for successful reentry to the community.  

Security practices in a CI encompass policies and procedures that are in alignment with the institution’s policies and procedures. A collaborative environment with open communication between CI and the institution is integral to implementing security and personal safety procedures. CIs with the strongest security practices create a culture that understands and prioritizes the importance of security and programming to run an effective, safe, secure and productive correctional industry program within an institution. 

Rationale/Benefits

The CI workplace differs from the typical workplace in that the operation exists in a correctional environment and the workforce is made up of civilian staff and offenders. It is imperative that the overall security operations have open channels of communication and a continuity between CI and the institution, creating a well-balanced ‘security and personal safety mindset’ for staff and incarcerated individuals.  In a CI environment, security and personal safety remain a top priority, while ensuring production requirements and quality standards are met. 

It is essential that CI’s have a robust safety program to protect civilian staff and incarcerated individuals from workplace accidents and injuries. 

Practices

Please note that the following best practices may need to be modified by each CI based on departmental regulations, institutional policies and contingent upon other factors including, but not limited, physical plant design, level of security, location of plant, level of programs, cost of implementation and state/local statutes. The following best practices have been shown by research and/or experience to produce optimal results for CI programs, however, it is recognized that not all-practices cited can be implemented throughout all CI operations.

  1. Follow Sound Security Control Policies

    Policies and procedures are necessary to ensure strict security practices.  In addition to standard operating procedures, CI safety and security policies must follow the institution’s policies and departmental procedures. Operation-specific policies should be developed in cooperation with the institutional security staff, as applicable. If a policy or procedure is restricted, staff must ensure that it is not distributed to the public or incarcerated individuals.  Unrestricted policies should be distributed to staff and incarcerated individuals to ensure that they are understood and followed. Policies should be reviewed annually. 

 

  1. Tool Control Policies

    Should ensure proper classification, control and accountability for all tools.  Tools are typically classified in groups that identify their potential to cause major bodily harm, effect an escape or facilitate a security risk. These classifications utilize a scoring system, such as A, B or C or I, II or III.  These classifications also identify which custody level, incarcerated individual, or program can use which tools with or without direct supervision. 

 

 A tool control officer or other staff should be assigned to the program with responsibility for:

 

  • Maintaining a master inventory and sub inventories of individual tool boards, boxes, cabinets, vehicle tool kits, etc.

     

  • Receipt of new tools and disposal of worn-out/broken/excess tools, ensuring there are safeguards to prevent delivery of tools throughout the institution. 

 

Tools maintained within the operation should be limited to those used on a weekly basis.  Seldom-used tools should be inventoried and kept in a secure location. 

 

At a minimum, supervising staff should inventory tools at the beginning and end of all shifts. Security staff should conduct a full audit and comprehensive review of the tool room not less than every six months.

 

All contractors and temporary staff working inside the operation should receive written instructions outlining their responsibilities regarding tool control. In addition, their tools should be inventoried at the beginning and end of each work day, or as required by institutional policy.   

  1. Key Control Policies 

    Should provide control and accountability for all keys and locking systems and establish key control and inventory procedures that restrict distribution.  Policy should also include procedures for loss, breakage and failure to return keys. Keys to all areas within the CI should be readily available by custody in the event of an emergency.  

A key control officer or other staff should be assigned to the program with responsibility for:

  • Maintaining a key inventory 

  • Issuing keys to staff depending on their area of responsibility

  • Controlling and maintaining locking devices 

Daily operational keys should be issued from a secure control system (staffed or mechanical) and be required to be turned in daily. Security keys should never leave the institution and all keys should be accounted for at the beginning and end of each shift.  Security keys should never be handled by incarcerated individuals. 

NIC recommends staff not carry personal keys in their possession and that a procedure for the storage of personal staff keys be developed. CIs should participate in an institutional policy review regarding the storage of personal keys to see if these recommendations can be implemented.

  1.    Chemical Control Policies 

Should ensure that all hazardous and/or caustic materials are kept in a separate storage area and locked at all times.  A perpetual inventory should be maintained and materials should be issued only by designated staff. 

Chemicals should only be issued to incarcerated individuals in the quantity required to accomplish the immediate task.  Unused chemicals should not be allowed in work areas at the end of the workday and should be inventoried and secured before incarcerated individuals leave the work area.  Label all hazardous material containers/dispensers to identify contents.  Safety Data Sheets (SDS) should be maintained and available for all hazardous materials. 

d)      Contraband Control 

CI’s should be trained in and follow institutional policies on identification, search and disposal of contraband.  Policies regarding allowable items for incarcerated individuals to have in the operation should be understood by CI staff. Custody and CI staff should be diligent in performing constant checks for contraband, particularly in industries with high rates of availability to receive and distribute contraband. CI staff should be accountable for approved personal items brought on site and maintain control of those items.

  • All contractors working inside the CI operation should receive written instructions outlining their responsibilities regarding contraband control.

    • Incarcerated  workers should not have access to staff uniforms or personal clothing at any time. Officer uniforms should be issued from a location outside of the CI operation. Where uniforms are manufactured in a CI operation, incarcerated individuals should never have access to a completed uniform. CI supervisors and staff should wear clothing that distinguishes them from incarcerated  workers.

     

  1.  

    Most incarcerated Individuals who work in CI have access to tools, manufacturing equipment and/or warehousing/trucking equipment. Proper incarcerated Individual assignment to CI is an important security factor.  Work with the institution to define policies for identifying and screening incarcerated Individuals for CI programs through classification, institutional behavior, group compliance, educational completion, etc.   

    1. Written Procedures 

      Institutional assignment procedures should define who is eligible to work in CI based on institutional policy and set minimum standards.  Standards ensure incarcerated Individuals have maintained acceptable behavior over a set period of time, as well as a commitment to bettering themselves. 

      1. Screening 

        1. Incarcerated Individual Behavior Agreement/Contract 

          1. Allowable items 

       Institutional risk reviews should be conducted prior to program assignment.  The screening process should include criminal history, victimology, history of violence, infraction behavior, medical/mental health concerns, documented behavior observations and gang affiliation. 

      Incarcerated Individuals working or training in CI should sign an Incarcerated Individual Behavior Agreement. This provides incarcerated Individuals with clear expectations and standards of behavior necessary to retain their job.  

      CI operations should clearly define allowable items for incarcerated Individuals.  The list should be reviewed and updated annually by the institution.  This sets expectations for a professional and uncluttered work environment, promotes effective searches and helps reduce contraband.  

  2.  

    Continuing education, training, coaching and modeling ensure staff are exposed to the knowledge and tools necessary to provide the highest level of personal safety and security in the CI setting.  The American Correctional Association (ACA) recommends 120 hours of pre-service training and an additional 80 hours of job specific training.  Safety and security training should be ongoing and frequent.

  3. Safety programs 

    Are developed to ensure safe and healthful working conditions for all staff and incarcerated Individuals. The program should provide detailed information on the following: 

    • Protecting staff and incarcerated Individuals from job-related injuries and health impairment 

      • Preventing accidents and fires 

      • Planning for emergencies and emergency medical procedures

      • Identifying and controlling physical, chemical, and biological hazards in the workplace

      • Communicating potential hazards to staff and incarcerated Individuals 

      • Assuring adequate housekeeping and sanitation

  4. In addition to the policies, procedures and practices identified above, CI staff should be trained in:

    • Incarcerated Individual manipulation, staff complacency and overfamiliarity with incarcerated Individuals.

      • Situational Awareness

        • Remaining alert and aware of the environment around them

          • Identifying what constitutes irregular behavior and warning signs of incarcerated Individual disturbances

  • Effective communication with incarcerated Individuals such as utilizing motivational interviewing techniques.  

  1. Staff Equipment 

    Provide staff with necessary safety equipment to supervise incarcerated Individuals.  This will be institution or state specific and may include radios, panic buttons, pepper spray, and others.

  • CI Staff should have radios programmed with a personal safety feature and tied into the institution’s personal alarm notification system.

  • Plants should have a public address system for mass communications, as applicable.

  • CI staff should be issued a personal alarm.

  1. Incarcerated Individual Training  

    Ensure that incarcerated Individuals receive basic safety training prior to being allowed to work on the operation floor.  Training should include hazardous workplace identification and reporting and mandatory training modules (i.e. personal protective equipment (PPE), fire extinguisher, blood borne pathogens, etc.).  Safety training on specific equipment should occur prior to operation. Safety awareness training should be conducted frequently.  

     

  2. Personal Protective Equipment (PPE) 

    Staff and incarcerated Individuals should be provided the necessary safety equipment for all assignments. 

  3. Safety Inspections 

    Staff should conduct comprehensive, documented safety inspections.  An inspector (non-operation staff) should perform a safety audit.  Violations posing an imminent threat should be corrected immediately. A plan should be developed to mitigate other documented deficiencies within 30 days.  

  4. Staff Accountability 

    Maintain compliance with institutional staff accountability procedures. 

  5. Implement Sound Occupational Health and Safety Programs

    It is mandatory that CI’s have a robust safety program to protect staff and incarcerated Individuals.  CI’s are responsible for providing a safe and healthful workplace and must comply with all applicable safety standards. 

    All staff are responsible to conduct their work in a safe manner, make recommendations to improve safety and health, notify supervisors of any accident involving injury, illness or near-miss.  Participate in safety awareness training weekly and formal safety refresher training semi-annually.  

  6. Safe Staffing Models 

    The process for determining adequate staffing for a CI operation should consider physical plant design, level of security, location of plant, level of programs and activities, equipment/tools used, and state and local standards and statutes to recommend a specific officer and CI staff-to-incarcerated Individual ratio. 

  7.  

    1. Counts 

      Incarcerated Individuals should be accounted for at all times. Per institutional policies and procedures, official and unofficial counts are required at set intervals during the day. In addition, situational (unofficial) counts are taken as circumstances dictate.  Report and document unaccounted-for incarcerated Individuals immediately. 

    2. Additional Counts

      CI programs may institute additional counts based on staff to incarcerated Individual ratio, custody level and the nature of the work or training. Many CIs have outside work crews.  The general location of all outside work crews should be known by the supervisor and institution’s control center at all times.  Official and unofficial count times may still apply. Staff supervising outside work crews should have a current picture ID of each incarcerated Individual, assigned to their supervision, with them whenever they are out of the institution.

    3. Defined Areas/Controlled Movement  

      Develop procedures to define all access areas for incarcerated Individuals, as well as prohibited access. Post clear signage limiting access to restricted areas.  For larger operations, clearly state defined areas in procedures and incarcerated Individual job descriptions.  Document and report incarcerated Individuals outside of assigned areas. 

    4. Staff Escorts 

      Develop procedures for incarcerated Individuals leaving the CI operation location outside of normal movement. Ensure that incarcerated Individuals are formally turned over to the appropriate staff prior to leaving the operation or when they arrive at the unit/pod, depending on institutional policy, and that the incarcerated Individual location is updated upon arrival and departure. 

  8.  

    1. Check-in/out Procedures

      Incarcerated Individuals arriving at or leaving a work location should be checked in/out with a photo ID, work roster verification or electronic scanning.

    2. Searches 

      CI staff should be trained in the proper method to perform routine searches of incarcerated Individuals whenever entering or departing their work area in compliance with Institutional policy and Prison Rape Elimination Act (PREA) guidelines. Written policy should clearly state the frequency of these searches and define gender-specific search procedures.

    3. Metal Detectors 

      Metal detectors should be used in operations where feasible.

  9.  

    Delivery trucks pose a high risk for escape and receipt of contraband.  Staff should check all incoming trucks and materials for contraband and order accuracy.  Custody and/or CI staff should thoroughly search all outbound trucks. Use of technology such as heartbeat monitors is recommended for high traffic operations. 

    1. Supervision 

      Incarcerated Individuals should be under direct supervision at all times during the loading / unloading process. 

    2. Material Search 

      Staff should conduct a search of all materials upon receipt. The use of an x-ray machine or other technology is recommended for material receipt, where feasible, with the potential for hidden contraband.

       

    3. Truck Driver Entry/Exit Procedures  

      All delivery trucks should be subject to search upon entering and exiting the premises or facilities. 

  10. Conduct Security Checks and Implement Vulnerability Assessments

    1. Conduct Routine Security Checks  

      In addition to CI policies and procedures regarding key, tool and movement control, routine security checks of all areas by CI staff are essential to providing security within the CI operation. 

  • CI supervisors should perform routine checks to ensure that all policies are being enforced.  Custody staff should also observe the operation and routinely conduct security checks. 

  • CI staff should regularly conduct thorough reviews/searches of all areas of the operation.

  • Develop written procedures for outside work crews.  Custody staff and CI management should randomly spot check outside work crews, documenting each contact. 

  • Conduct K-9 searches, if available, at each CI operation periodically.

    1. Implement Security/Vulnerability Assessments 

      Security audits are tools that identify and isolate possible security risks. CI programs should be included in the DOC’s security and performance audits.  In addition, a thorough security review of the CI should be conducted in conjunction with the DOC at least annually to review adherence to policies, procedures, standards and best practices.  It is imperative that all security deficiencies are corrected timely and refresher training on policy is provided if needed.  An audit should identify any weaknesses, deficiencies and areas of vulnerability. 

  • Train selected CI staff as security auditors and include them on DOC security auditing team if possible. Utilize them to conduct internal security audits of operations.

  • Create a security inspection instrument for operations in conjunction with the institution.

  • Conduct unannounced security inspections routinely.

  1.  

    In conjunction with custody staff, CI’s should actively participate in all drills associated with emergency procedures.  Practicing drills is important for staff and incarcerated Individual safety in an emergency.  Drills are a means of pointing out deficiencies in the plan, testing staff knowledge and equipment, practicing response, and building confidence with staff and incarcerated Individuals. All staff should be trained, prepared and know their responsibilities in the event of a crisis.   Types of drills include but may not be limited to Fire, Man-down, Fight/Riot and Natural Disasters.  

  2.  

    The layout, design, location within the institution, age and level of maintenance of CI operations have a direct impact on the level of security.

    1. Cameras, Alarms and Mirrors 

      Where possible, cameras and door alarms should be installed throughout all CI operations and monitored.  Doors leading to the outside of the plant should have an audible door alarm that notifies CI and institutional staff when a door is opened without staff approval.  Evaluate camera systems and coverage often to ensure blind spot coverage.  Convex mirrors should be used to provide additional coverage for corners and hallways.  

    2. Blind Spots/Line of Sight

      • Equipment Placement - Care should be taken in the initial layout of the operation to ensure clear line of sight whenever possible.  Line of sight should be taken into consideration when designing/ordering new equipment.

      • Material Storage - It is easy to create a blind spot with moveable boxes.  Boxes/pallets should be stacked so they do not interfere with the line of sight whenever possible.  Install cameras and mirrors where shelving interferes with line of sight. 

      • Clutter - CI’s should limit the supply of material, equipment and tools in the operation to the minimum amount needed.   Store excess material, equipment and tools in a secure location outside of the operation.  Keep operation clean and aisles clear at all times. 

    3. Incarcerated Individual Boundaries 

      • Signage 

Should be used to clearly delineate boundary areas for incarcerated Individuals.  Do not allow incarcerated Individuals to freely walk the operation or enter the tool room or office areas without a staff member present.  

  • Incarcerated Individual Stations 

 Do not allow incarcerated Individuals to lock desks or cabinets.  Incarcerated Individuals should not be allowed to create “comfort stations” with personal possessions, photos, magazines and/or food.  

  • Telephones 

If incarcerated Individuals have access to telephones as part of their regular job duties, where appropriate, lock the telephones with a passcode or require the incarcerated Individual to go through a main switch board.  Telephone printouts should be closely monitored for unauthorized use by incarcerated Individual workers.  Such telephones are preferably equipped with monitoring and recording capability. 

  • Computers 

Develop written policy/procedures that allow incarcerated Individual use of computers and computer technology as part of their work assignment.  Policy should define incarcerated Individual internet access, if applicable.  Keep all computers or equipment with external access (fax, copier and modem) in secured areas.  An audit of computers should be conducted regularly by knowledgeable staff to prevent abuse or unauthorized use of systems. 

  1.  

    1. Scrap Metal 

      For CI programs located inside facilities and depending on custody level, all waste product that can be made into a weapon must be collected, secured and disposed of in secure waste bins at the end of every shift. Make sure all scrap metal is accounted for and secured prior to incarcerated Individuals leaving metal plants. Secure waste bins may only be emptied in areas not accessible by incarcerated Individuals. Incarcerated Individual involvement in this activity should be supervised. 

    2. Sharps Containers 

      Strategically place locked sharps containers in areas for disposal.  Inventory and dispose of sharps frequently.  Incarcerated Individual involvement in this activity should be supervised. 

    3. Waste Clutter 

      Work areas should remain clean and clear of all waste and debris.

    4. Trash Storage and Removal 

      Waste bins should be located throughout the work areas and emptied daily. Dispose of any waste that could be made into a weapon in a secure waste bin.

    5. Hazardous Waste 

      Disposal of hazardous waste should be consistent with OSHA codes. All hazardous materials issued to incarcerated Individuals or drawn by staff from a point of supply and put in containers should be labeled to identify contents. 

  2.  

    Developing a cooperative partnership with the institution centered on respect, collaboration and proactive communication is imperative to ensuring security of the incarcerated Individuals and safety of all staff. The CI and the institutional staff must work together and respect each other to accomplish all objectives.

    1. Institutional Leadership 

      The CI operation manager(s) and the institution’s head and custody managers are the leaders in setting the tone of cooperation and respect.  The CI operation manager should attend appropriate security and safety related institutional meetings led by the warden/superintendent or designated staff. 

    2. Building Relationships through Communication 

      Communication is the key to building a strong relationship between the institution and CI staff. 

    3. Training 

      CI staff should attend orientation and required DOC training with department staff.    

  3.  Obtain compliance verification in conjunction with the DOC or through external sources.

    1. PREA Audits

    2. Security Audits

    3. Safety and Environmental Audits

    4. ACA Audits

Measurements

  • Employee Turnover

    • Loss Time Worked

      • Employee Accidents - OSHA 300 Log

      • Assaults on Staff

      • Security Audit Incidents

      • Safety Audit Incidents

 

Resources

Websites

https://www.aca.org/ACA_Member/ACA/ACA_Member/Standards_and_Accreditation/

ACA Standards

 

https://www.osha.gov/dcsp/compliance_assistance/sampleprograms.html

OSHA Safety Program Samples

https://www.osha.gov/sites/default/files/2018-12/fy15_sh-27666-sh5_SituationalAwareness.pptx

OSHA - What is Situational Awareness?

https://www.corrections1.com/officer-safety/articles/how-active-reactions-improve-situational-awareness-in-corrections-SQlpQhdcR07oLlVB/

Corrections1 Situational Awareness

TOOLS

NIC Staffing Analysis Clearing House – Includes NIC’s 9-Step Staffing Analysis flow chart - http://correction.org/staffing-analysis-clearinghouse/

Prison Staffing Analysis: A Training Manual with Staffing Considerations for Special Populations -https://nicic.gov/prison-staffing-analysis-training-manual-staffing-considerations-special-populations

ACA Accreditation Policy and Procedure Manual 

https://aca.org/common/Uploaded%20files/Standards/Accreditation%20Manual%20-%20Aug%202020%20Final.pdf

Sample Behavior Agreement on next page

CORRECTIONAL INDUSTRIES

WORKER BEHAVIOR AGREEMENT

SDD/CDC-TUMWATER WAREHOUSE

WORKER NAME/DOC#:

DATE OF HIRE:

GENERAL

CIVILITY & HARASSMENT FREE WORKPLACE

Courtesy and respect are the hallmarks of any successful endeavor. Every worker, staff member, visitor and/or person(s) that come into contact with a Correctional Industries program is deserving of courteous interaction(s) and a harassment free environment. Negative behavior or harassment whether verbal, physical, by gesture or by lack of an action is categorically unacceptable and subject to the appropriate sanctions. Sanctions could range from suspension, demotion, reduction in pay and/or include termination from employment with Correctional Industries.

DRESS STANDARDS

All CI workers are expected to report to their work assignment presentable and reasonably well groomed. Clothing worn will be clean and in good repair. All workers will report to work dressed in DOC state issued clothing. Personal clothing is not authorized in Correctional Industries program areas.

JOB ASSIGNMENTS & EXPECTATIONS

CI workers will be hired/assigned for a specific job, but are expected to perform duties as needed in any area of Correctional Industries. Available schedules, transfers and other factors make it necessary to temporarily place workers into a different department from time to time. Assignments will only be given by CI/DOC supervisors. Workers are expected to follow all lawful directives given from any CI supervisor or DOC staff member.

COMPENSATION

All new CI workers will be assigned a minimum (30) day probation and start at the base level compensation rate. After satisfactorily completing the initial probation period, workers will become eligible for pay increases per DOC Policy (710.400).

PROBATION & PLACEMENT

At the end of the (30) day probation period, workers will be reviewed for either permanent placement, extended probation or termination. Good attitude, the ability to follow directions and complete assignments is key for successful employment with CI. Unsatisfactory performance or violation of any DOC/CI Policy or Rule is grounds for disciplinary action(s) up to and including termination. 

RULES/GUIDELINES

  1. I will be in my assigned work area at all times.
  2. I will wear my ID tag at all times, unless otherwise authorized by my supervisor.
  3. I will not engage in horseplay at any time.
  4. I will wear all safety/protective equipment as required.
  5. I will follow lawful directives/instructions from all CI/DOC staff.
  6. I will not take personal property to or from work, including clothes/shoes, radios, headphones, newspapers, pictures, magazines, personal letters, or any other personal items that are not listed on the CI workplace Allowable Items List (AIL).
  7. I will turn in any money found, including change or currency to my supervisor(s).
  8. I will not touch or handle any firearm, explosives/devices and if found will report it to my supervisor(s) immediately.
  9. I will not hold conversations with non-DOC personnel unless it is work related and necessary to complete assigned duties.
  10. I will not smoke/chew or possess tobacco products or related paraphernalia at anytime.
  11. I understand that I will be returned to the institution immediately and subject to disciplinary action(s) for any verbal or physical altercation(s) occurring while working for CI (Offsite).
  12. I will not use telephones or any other electronic communication devices unless authorized and/or required by job assignment.
  13. I understand that obscene gestures or language will not be tolerated and I will not engage in any type of sexual activity with anyone.
  14. I will not misuse, deface or destroy state property, machinery, tools, materials or finished goods.
  15. I will not be under the influence of any substance that is not prescribed by the appropriate medical authority while working for CI.
  16. I understand that I am not authorized to use computers unless it is job related and part of my assigned duties.
  17. I will only use designated/authorized restrooms.
  18. I will not enter any restricted area unless directed to do so by an authorized CI/DOC staff member. 
  19. I will not enter into a vehicle cab or boat unless directed by a CI/DOC staff member.
  20. I will report all safety violations and/or hazards to my supervisor(s) immediately.
  21. I will report all personal injuries that occur while working for CI to my supervisor immediately.
  22. I will report to my supervisor if I am unable to continue to work due to illness.
  23. I will team up with another crewmember when I have to move or lift any large/heavy items or equipment.
  24. I will notify my supervisor immediately any damage that I do to property will working for CI.
  25. I will only use the proper Material Handling Equipment (MHE) for each particular job.
  26. I will only use tools and equipment that I have been trained on and authorized to operate.
  27. I will return all work related equipment and tools to my supervisor prior to return to the institution.
  28. I will not take, remove or relocate any item/property for any reason, unless necessary to complete my assigned tasks.
  29. I will not engage in any activities other than work (i.e., playing cards, reading books or magazines or work on personal projects, etc…) while working for CI.
  30. I will consume food/beverages in designated areas only.
  31. I will not violate any DOC/CI Policy while working for CI.

CI BUS TRANSPORT RULES

  • Workers are to board the bus in an orderly fashion.
  • When boarding the bus, workers will sit in the designated crew seating area and leave the last seat row open for staff.
  • Communication on the bus will be done in a quiet conversational tone.
  • Workers will not interact or communicate with anyone outside the bus. 
  • Workers will remain seated while the bus is in operation.
  • Workers will follow all directives given by CI/DOC staff during transport.
  • Upon arrival at the CI Warehouse/CCCC, workers will remain seated until directed by staff to unload.
  • Workers will unload from the bus in an orderly fashion.

I hereby acknowledge that I have read and understand all the rules and guidelines that have been outlined in this CI Worker Agreement.

 

WORKER NAME/DOC#(PRINT):                                          DATE:                    

WORKER SIGNATURE:                                                      DATE:                    

SUPERVISOR SIGNATURE:                                                DATE: