offical seal
Human Capital Management
#190111-I10C-I29


Supplemental Questionnaire

Last Name First Name
 
1.

Please select the option that describes your current or most recent employment status with the State of Oklahoma.

Current DOC employee or former DOC employee with reinstatement rights
Current employee of another State of Oklahoma agency (not DOC)
Former employee of another State agency (reinstatement)
None of the above
2.

Please verify that your employment status as indicated above is/was as an employee with permanent status in the classified service.

Yes No
3.

If you indicated that you worked at another State of Oklahoma agency, please type the name of that agency in the box.  If you worked at DOC, please type DOC in the box.  If you indicated that you have not held permanent status in the classified service, please type N/A in the box.

4.

Do you have legal status to work in the United States?

Yes No

 

The Prison Rape Elimination Act (§115.17) requires that the Department of Corrections ask the following questions prior to hiring or promoting staff (please check a response to each question):


5.

Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution?

Yes No
6.

Have you ever been convicted (or civilly or administratively adjudicated) of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?

Yes No
7.

Have you ever engaged in any incidents of sexual harassment?

Yes No
8.

If you answered yes to questions 5, 6 , or 7, please explain:


 

P.R.E.A. §115.17(g):  “Material omissions regarding such misconduct, or the provision of materially false information, shall be grounds for termination.”