"Community Work Program Request Form" - Montana

Community Work Program Request Form is a legal document that was released by the Montana Department of Corrections - a government authority operating within Montana.

Form Details:

  • Released on March 28, 2011;
  • The latest edition currently provided by the Montana Department of Corrections;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Corrections.

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STATE OF MONTANA
DEPARTMENT OF CORRECTIONS
COMMUNITY WORK PROGRAM REQUEST FORM
PROGRAM INFORMATION
Requesting Agency
State Agency
City
Number of Offenders
Request Date
Non Profit
County
Needed
Internal
External
School District
Other:
Contact Person:
Telephone Number:
Offender(s) Name, DOC ID# and Living Location:
Program Description:
Location: (Provide sufficient detail for emergency assistance)
Program Work
Payment Terms:
Hours:
Projected Start Date:
Projected Completion Date:
FACILITY INFORMATION
Facility/Program Name:
Region (If applicable):
Work Program Supervisor Name:
Telephone Number:
Note Agency Program Responsibilities:
REQUESTING AGENCY OR ORGANIZATION INFORMATION
Transportation Provided By
Method of Transportation: (Indicate One)
Vehicle Capacity
Requesting Agency
Van
Pickup
Bus
Yes
No
Other: (Specify)
Tools, Supplies and Safety Equipment to be used:
Provisions for food and water:
Name(s) of Supervisor(s) who will provide safety instructions and oversee work:
Provisions for access to restrooms (Identify Type and Location)
Identify additional assistance being provided by requesting agency:
Requesting Agency Program Supervisor
Name:
Telephone Number:
ACCOMODATIONS PROVIDED BY MONTANA DEPARTMENT OF CORRECTIONS
(To be filled out jointly with Requesting Agency)
Size of Offender Work Force:
Number of Correctional Staff Assigned:
Special Needs (i.e. clothing, equipment)
Mobile Communications (i.e., cellular phone, hand held radio):
Food Service:
Vehicles:
Armory:
Other:
DOC 5.1.3 (Attachment) p. 1 of 2, Offender Community Work Programs – Revised
03/28/11
STATE OF MONTANA
DEPARTMENT OF CORRECTIONS
COMMUNITY WORK PROGRAM REQUEST FORM
PROGRAM INFORMATION
Requesting Agency
State Agency
City
Number of Offenders
Request Date
Non Profit
County
Needed
Internal
External
School District
Other:
Contact Person:
Telephone Number:
Offender(s) Name, DOC ID# and Living Location:
Program Description:
Location: (Provide sufficient detail for emergency assistance)
Program Work
Payment Terms:
Hours:
Projected Start Date:
Projected Completion Date:
FACILITY INFORMATION
Facility/Program Name:
Region (If applicable):
Work Program Supervisor Name:
Telephone Number:
Note Agency Program Responsibilities:
REQUESTING AGENCY OR ORGANIZATION INFORMATION
Transportation Provided By
Method of Transportation: (Indicate One)
Vehicle Capacity
Requesting Agency
Van
Pickup
Bus
Yes
No
Other: (Specify)
Tools, Supplies and Safety Equipment to be used:
Provisions for food and water:
Name(s) of Supervisor(s) who will provide safety instructions and oversee work:
Provisions for access to restrooms (Identify Type and Location)
Identify additional assistance being provided by requesting agency:
Requesting Agency Program Supervisor
Name:
Telephone Number:
ACCOMODATIONS PROVIDED BY MONTANA DEPARTMENT OF CORRECTIONS
(To be filled out jointly with Requesting Agency)
Size of Offender Work Force:
Number of Correctional Staff Assigned:
Special Needs (i.e. clothing, equipment)
Mobile Communications (i.e., cellular phone, hand held radio):
Food Service:
Vehicles:
Armory:
Other:
DOC 5.1.3 (Attachment) p. 1 of 2, Offender Community Work Programs – Revised
03/28/11
HEALTH AND SAFETY REVIEW
(Complete only if the administrator or Contract Placement Bureau Chief requests a safety and health review.)
I have evaluated the above referenced program , which has also been reviewed by certified personnel provided by the requesting entity. My decision regarding the
program is as follows:
Approved
Disapproved
Investigations Bureau Chief, or Designee
PROGRAM RECOMMENDATION AND AUTHORIZATION
Approved
Denied
Reason for Denial (i.e., staff resources, etc.)
Signature:
Date:
Requesting Agency Representative
Signature:
Date:
Warden/Superintendent/Facility Administrator
Signature:
Date:
Contract Placement Bureau Chief (if necessary)
This form is filled out by the requesting party and submitted to staff designated to evaluate the offender work assignment.. This form must be attached to the
Community Work Program Screening Form.
This agreement shall be effective upon signature and shall remain in effect until the program completion date or until such time as either party terminates said
agreement.
DOC 5.1.3 (Attachment) p. 2 of 2, Offender Community Work Programs – Revised
03/28/11
Page of 2