Loading...
HomeMy WebLinkAboutSH22-015 - USM MODIFICATION - SIGNED BY SHERIFF - WAITING ON SIGS FROM USMU. S. Department of Justice United States Marshals Service Modification of Intergovernmental Agreement 1. Agreement No. 2. Effective Date 3. Facility Code(s) 4. Modification No. 5. DUNS No. 85-10-0004 February 1, 2022 OBU 1 NIA 6. Issuing Federal Agency 7. Local Government United States Marshals Service KITTITAS COUNTY JAIL Prisoner Operations Division 205 W 5TH AVE Intergovernmental Agreements Branch ELLENSBURG, WA 98926 CG -3, Suite 300 Washington, DC 20530-0001 8. Appropriation Data 9. Per -Diem Rate 14. Guard/Transportation Hourly Rate 15X 1020 N/A NIA 11. EXCEPT AS PROVIDED SPECIFICALLY HEREIN, ALL TERMS AND CONDITIONS OF THE IGA DOCUMENT REFERRED TO IN BLOCK 1, REMAIN UNCHANGED. TERMS OF THIS MODIFICATION: The purpose of this modification is to add the following revisions to the current IGA: 1. Replacing "Purpose of Agreement and Security Provided" section with Addendum #1 (see attached) 2. Adding new language to "Medical Services" section pertaining to Covid-19 and other infectious diseases (see Addendum 42 attached) 3. Adding "Pregnant or Post -Partum Prisoners" language to all Guard Services' sections (see Addendum 43 attached) 4. Adding new "Video Teleconferencing" section (see Addendum #4 attached) 5. Adding new "Voter Registration" section (see Addendum #5 attached) 6. Adding new "Body Camera Information Requests" section (see Addendum 46 attached) 7. Adding new language to "Restrictive Housing and Suicide Prevention" (see Addendum 97) NO OTHER TERMS OR CONDITIONS ARE AFFECTED BY THIS CHANGE 12. INSTRUCTIONS TO LOCAL GOVERNNUENT FOR EXECUTION OF THIS MODIFICATION: A. ❑ LOCAL GOVERNMENT IS NOT REQUIRED B. ® LOCAL GOVERNMENT IS REQUIRED TO SIGN TO SIGN THIS DOCUMENT THIS DOCUMENT AND RETURN ALL COPIES TO U. S. MARSHAL 13. APPROVALS A. LOCAL GOVERNMENT B. FEDERAL GOVERNMENT Signature Signature SNY R I r t" - I - 271 Assistant Chief. Procurement TITLE DATE TITLE DATE U. S. Department of Justice United States Marshals Service Modification of Intergovernmental Agreement Agreement Number: Page 2 of 5 85-10-0004 • Administration 1. Federal prisoners shall be housed in a manner consistent with the Federal Perfonnance Based Detention Standards (FPBDS) subset utilized by the USMS Detention Facility Review Program. These standards are set forth in Form USM -218 (provided as an attachment to this modification). Facilities shall follow the current standards summarized in Form USM -218 and any other standards required by an authorized agency whose prisoners are housed by the Local Government pursuant to this agreement. 2. The FPBDS can be found at: http://www.usmarshals.gov/prisoner/detention-standards.htm 3. KITTITAS COUNTY JAIL shall comply with Congressional mandates, federal laws, Executive Orders and all existing KITTITAS COUNTY JAIL policies. KITTITAS COUNTY JAIL shall provide a means for verification of any state inspections, accreditation, and, if applicable, any alternative correctional facility acereditations such as an accreditation from the American Correctional Association accreditation. 4. All work assignments for unsentenced Federal prisoners must be voluntary. 5. The Local Government shall conduct initial and periodic background and reference checks of applicants, employees, contractors, and volunteers. All allegations of staff misconduct shall be investigated and reported to law enforcement as appropriate. Staff misconduct involving or affecting USMS prisoners shall be reported to the local district United States Marshal (USM), Chief, or their designee and to the USMS Prisoner Operations Division (POD) at PODCoCIng uiries a,usdoj.gov. 6. The Local Government shall maintain written policies and procedures that describe all facets of facility operations, maintenance, and administration. The Local Government shall maintain written contingency and emergency plans for situations including but not limited to riots, hunger strikes, disturbances, escapes, hostage situations, and mass prisoner relocation. 7. The Local Government shall maintain records of annual fire safety inspections. The Local Government shall maintair dangerous materials in accordance with government regulations. 8. The Local Government shall maintain an objective review, classification, and housing process. Federal prisoners shall be clearly identified as USMS prisoners in the classification system. 9. The Local Government shall ensure Federal prisoners under the age of 18 receive an age-appropriate diet, exercise, and education. 10. The Local Government shall ensure Federal prisoners under the age of 18 or charged as a juvenile shall be separated by sight and sound and out of regular contact with adult prisoners, except in emergency situations or approval from the court. 11. The Local Government shall keep the Facility clean and in good repair. Food service equipment shall meet established health and safety codes. The Local Government shall provide a minimum of three (3) meals per day that are varied and nutritionally adequate. The Local Government shall provide safe and clean space and items for proper prisoner hygiene. 12. The Local Government will provide clean and serviceable bedding and clothing. Clothing and shoes shall be properly sized and temperature and weather appropriate. The Local government shall provide appropriate attire upon release. 13. The Local Government shall properly inventory, store, and return prisoner property upon release. 14. The Local Government shall provide adequate accommodations for prisoners with disabilities once accepted by the Local Government. 15. The Local Govermnent shall prohibit discrimination on the basis of disability, race, gender, sexual orientation, religion, and national origin in the provision of services, programs, and activities. U. S. Department of Justice United States Marshals Service Modification of Intergovernmental Agreement Agreement Number: Page 3 of 5 85-10-0004 16. The Local Government shall provide prisoners with reasonable opportunities to participate in religious practices, exercise, and access to mail, telephones, personal legal materials and legal reference materials or confidential counsel. 17. The Local Government shall maintain a grievance program with at least one level of appeal. The grievance procedures shall be made available to prisoners • Medical Services I. The Local Government shall maintain written procedures that describe actions taken in the event of a prisoner's death, assault, or medical emergency to include notification to the USMS. 2. The Local Government shall provide a medical and mental health screening upon admission to the Facility. The Local Government shall inform prisoners how to access health services. 3. The Local Government shall notify the local USMS district office of a� infectious disease outbreak 4. The Facility is encouraged to purchase non -OTC medications for USMS prisoners through the USMS' National Managed Care Contract (NMCC) Discount Pharmacy Program. 5. The USMS will not reimburse the detention facility for medical payments made on behalf of USMS prisoners in the absence of a specific arrangement approved in writing by the USMS. 6. The Facility shall have in place an adequate infectious disease control program which includes testing of all Federal prisoners for Tuberculosis (TB) in accordance with National Commission on Correctional Health Care (NCCHC) Standards for Health Services in Jails. TB testing shall occur with 14 days of intake (unless current TB tests results are available), be promptly documented in the Federal prisoner's medical record and the results forwarded to the local USMS District within thirty (30) days of intake. Special requests for expedited TB testing and clearance (to include time sensitive moves) shall be accomplished through advance coordination by the Federal Government and Local Government. 7. The Local Government shall immediately notify the Federal Government to include the local district office of any cases of suspected or active TB or any other highly communicable diseases such as but not limited to Coronavirus Disease (COWD), severe acute respiratory syndrome (SARS), Avian Flu, Methicillin -Resistant Staphylococcus Aurcus (MRSA), Chicken Pox, etc., which might affect scheduled transports or productions. 8. Indigent Federal prisoners shall not be denied medical evaluation and treatment for failure to provide a co -payment Optional Guard/Transportation Services to/from Medical Facility I . The Local Government agrees to provide additional personnel if requested by the USMS to enhance specific requirements for security, prisoner monitoring, and contraband control. Federal prisoners are not permitted to use the telephone, intemet or WIN enabled devices, or to receive outside food, drinks, or deliveries (including flowers) without consent from the USMS. The Local Government shall restrain Federal prisoners by attaching at least one extremity to the hospital bed, stretcher, or chair at all times when medically possible. Pregnant or postpartum prisoners should not be restrained. Postpartum is the twelve -week period following childbirth, miscarriage, or abortion. See First Step Act provision for more information. U. S. Department of Justice United States Marshals Service Modification of Intergovernmental Agreement Agreement Number: Page 4 of S 85-10-0004 • Optional Guard/Transportation Services to/from U.S. Courthouse Each prisoner will be frilly restrained in handcuffs, waist chain, and leg restraints during transportation unless otherwise authorized by the USMS. Pregnant or postpartum prisoners should not be restrained. Postpartum is the twelve -week period following childbirth, miscarriage, or abortion. See First Step Act provision for more informati Deviations from full restraints must be documented and reported monthly to the local district USM, Chief, or their designee and to the USMS POD at PODCoCinguiries cr,usdoi.gov. Optional Guard/Transportation Services to Justice Prisoner & Alien Transportation System (JPATS) Each prisoner will be fully restrained in handcuffs, waist chain, and leg restraints during transportation unless otherwise authorized by the USMS. Pregnant or postpartum prisoners should not be restrained. Postpartum is the twelve -week period following childbirth, miscarriage, or abortion. See First Step Act provision for more information. Deviations from full restraints must be documented and reported monthly to the local district USM, Chief, or their designee and to the USMS POD at PODCoCIn.guiries@.usdon.gov. Optional Guard Services to Video Teleconference Hearings within Facility Each prisoner will be fully restrained in handcuffs, waist chain, and leg restraints during transportation unless otherwise authorized by the USMS. Pregnant or postpartum prisoners should not be restrained. Postpartum is the twelve -week period following childbirth, miscarriage, or abortion. See First Step Act provision for more information. Deviations from full restraints must be documented and reported monthly to the local district USM, Chief, or their designee and to the USMS POD at PODCoCinguiries@usdoi.gov Video Teleconference Hearings within the Facility 1. If available, the facility shall furnish, as applicable to this agreement, all things necessary for, or incident to, providing Video Teleconference (VTC) hearings within the facility. When VTC equipment is not available at the facility, the Federal Government, in coordination with the Courts, may assist with providing VTC equipment and ancillary items to the facility. m #5 • Ensuring Access to Voter Registration for Eligible Individuals in Federal Custody 1. The facility, to the extent practicable and appropriate, will provide federal prisoners educational materials related to voter registration and voting and, upon request by the federal prisoner, facilitate voting by mail by prisoners who are eligible to vote under the laws of the applicable jurisdiction. The facility will work with state and local election officials and, in appropriate circumstances, may also work with other reliable sources of voter information to assist federal prisoners with voter registration, voting by mail, and notification of upcoming elections. This clause does not endorse or advocate in support of or in opposition to any candidate or political party. U. S. Department of Justice United States Marshals Service Modification of Intergovernmental Agreement Agreement Number: Page 5 of 5 85-10-0004 Body Worn Camera Information Requests 1. tf the Local Government adopts a Body Worn Camera (BWC) use policy that mandates use of BWC for transport or other activities covered under the IGA, the agency shall, upon request by USMS, provide USMS with the audio/video footage and any metadata captured by the BWC pertaining to USMS prisoner incidents. The audio/video footage and any metadata may be requested by the USMS Body Worn Camera Program and the USMS Office of General Counsel_ The agency agrees that no BWC footage depicting a USMS prisoner will be released without advance written notification to the USMS. dendum #7 Restrictive Housing and Suicide Prevention 1. For the purposes of this agreement, "vulnerable population" refers to prisoners who are more likely to be victimized in confinement settings, including but not limited to: juveniles; young adults (age 18-24 at time of admission through conviction); prisoners with serious mental illness; lesbian, gay, bisexual, transgender, intersex, and gender nonconforming prisoners; pregnant and postpartum prisoners; and prisoners with medical needs. NO OTHER TERMS OR CONDITIONS ARE AFFECTED BY THIS CHANGE UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) U.S. Department of Justice United States Marshals Service Detention Facility Review Date of Detention Facility Review (DFR) Name of Detention Facility Inspector Conducting DFR F- -- 17 FACILITY FACTS FACILITY OVERVIEW Facility Name Physical Address Phone Number Fax Number City State Zip Code County District Contract/Agreement Number Contract/Agreement Type (Private, IGA, LUA) Expiration Date Closest USMS Office Name Driving Time from Closest Driving Distance from Date of Last USMS USMS Office Closest USMS Office Detention Facility Review minutes miles Points of Contact (If needed, use "Other Notes Section" on last page to document more than one point of contact.) Title Name Type of Contact Phone Number Extension Email Address NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 1 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Prisoner Information (Annotate the number of prisoners per category) Security Staff Information (Annotate number of authorized and filled positions per facility's staffing plan) Authorized Filled Warden Assistant Warden Chief of Security Shift Supervisors Other Supervisors Corrections Officers Transportation Officers Perimeter Security Restrictive Housing Security Other Security NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipients} Any unauthorized review. use, disclosure, or distribution is prohibited If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 2 of 22 Rev. 07121 Adult Male Adult Female Juvenile Male Juvenile Female Total Facility Bed Capacity Facility Average Daily Population (Last 12 Months) LISMS Average Daily Population Local/Non-Federal Average Daily Population - '— Bureau of Prisons Average Daily Population ICE Average Daily Population Security Staff Information (Annotate number of authorized and filled positions per facility's staffing plan) Authorized Filled Warden Assistant Warden Chief of Security Shift Supervisors Other Supervisors Corrections Officers Transportation Officers Perimeter Security Restrictive Housing Security Other Security NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipients} Any unauthorized review. use, disclosure, or distribution is prohibited If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 2 of 22 Rev. 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Medical Staff Information (Annotate number of authorized and filled positions per facility's staffing plan) Authorized Filled Physician F Physician's Assistant Nurse Practitioner F Registered Nurse Licensed Practical Nurse Mental Health Professional E7 Other Medical Staff Contraband List facility's total number of contraband incidents since last USMS DFR (if applicable). Drugs or Alcohol Drugs or Alcohol Paraphernalia Electronic Devices I - -7 [ .1 Electronic Device Accessory Weapon Tool _ Incidents List facility's total number of incidents since last USMS DFR (if applicable). Suicides Suicide Attempts Escapes Escape Attempts Physical Assaults on Prisoners Physical Assaults on Staff Health Care Grievances Natural Deaths Sexual Assaults on Prisoners Sexual Assaults on Staff Homicides Riots/Disturbances F F Overdose Deaths Overdoses Use of Force Excessive Use of Force F7-- 17 -_ NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL Information which is for the sole use of the intended recipient{s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient. please contact the sender and destroy all coples of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 3 of 22 Rev 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Was the USMS notified of all incidents involving USMS prisoners? (' Yes (— No Incidents Not Reported (If needed, use "Other Notes Section" on last page to document more than one incident.) Incident Type Use Incident types listed above) Incident Subtype (Leave blank Date of Incident Remarks Court Action (If needed, use "Other Notes Section" on last page to document more than one action) Are there any court orders or pending major litigation affecting the facility? C` Yes C No Case Name/Case Number Functional Area Date of Court Filing ADMINISTRATION AND MANAGEMENT Policy Development and Monitoring Does the facility maintain policies and procedures that describe facility operations, maintenance and administration? Yes (' No Do policies have a date documenting the last time the responsible facility man agerladministrator reviewed them to ensure they remain current, accurate and relevant to the facility's operation? C' Yes (' No If 'Yes', Date of Last Internal Review Policy Communication and Access Are policies and procedures communicated to all employees? C' Yes C No Does staff have 2417 access to policies and procedures? C Yes r No Prisoner Property and Money Does the facility properly inventory prisoner property? (- Yes (' No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review. use, disclosure, or distribution is prohibited. If you are not the intended recipient, pfease contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 4 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDHLAW ENFORCEMENT SENSITIVE (When Completed) Does the facility properly store prisoner property? I^ Yes (- No Does the facility properly return prisoner property? (- Yes t^ No Does the facility properly inventory prisoner money? (- Yes (' No Does the facility properly store prisoner money? (' Yes C' No Does the facility properly return prisoner money? (- Yes (' No Prisoner Release Has the facility erroneously released ANY prisoner(s) during the review period? (- Yes (- No Total number of non-USMS prisoners erroneously released Accommodations for Prisoners with Disabilities Total number of USMS prisoners erroneously released If the facility accepts prisoners with disabilities, are adequate accommodations made available for these prisoners? (' Yes C No Contingency/Emergency Plans Does the facility have a written emergency plan in place for situations that threaten facility security? (e.g., riots, hunger strikes, disturbances, escapes, and hostage situations.) (- Yes (' No Is a hard copy of the emergency plan available for incorporation into the district's detention plan? C Yes (' No Does the emergency plan have a date documenting the last time the responsible facility manager/administrator reviewed the policy to ensure it remains current, and relevant to the facility's operation? C Yes C No If 'Yes', Date of Last Emergency Plan Review Does the facility have a written contingency plan in place for situations involving mass prisoner relocation? (e.g., weather, fire, flooding, facility not habitable.) ( Yes (' No Is a hard copy of the contingency plan available for incorporation into the district's detention plan? (' Yes (' No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited If you are rat the intended recipient. please contact the sender and destroy all copies of this document. Any Protected Health Information contained it this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal H€PAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDI/LAW ENFORCEMENT SENSITIVE (When Completed) Page 5 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Does the contingency plan have a date documenting the last time the responsible facility manager/administrator reviewed the policy to ensure it remains current, and relevant to the facility's operation? (' Yes (- No If'Yes`, Date of Last Contingency Plan Review Does the facility's contingency plan include the USMS prisoners housed at the facility? C' Yes (- No Staff Background Checks Does the facility verify identity of employees, contractors and volunteers prior to hiring via: Fingerprints (' Yes (- No Social Security Number i Yes (` No Date of Birth C' Yes ( No Are initial background checks completed for all employees, contractors, and volunteers prior to hiring? (^ Yes C^ No Does the facility conduct re -investigations of employees, contractors, and volunteers? (- Yes (' No C No If 'Yes', how often? (Every 2 years, every 5 years, every 10 years, or more than 10 years) Does the background check include verification of: No Derogatory civil records? Employment history for the past five (5) years? C Yes C' No Residency for the past three (3) years? C Yes C No Credit history to ensure no current delinquency? i Yes No Credit history to ensure no unresolved liens? (- Yes ( No Credit history to ensure no accounts in collection? C Yes C No Credit history to ensure no court-ordered judgments ? r Yes ( No Does the background check include verification that there are no'. Felony convictions? C1 Yes C No Disqualifying misdemeanor convictions? (' Yes C' No Derogatory civil records? C Yes ( No Alcohol dependencies? C` Yes C No Drug dependencies? (' Yes C' No Reporting/investigating Staff Misconduct How many administrative allegations of staff misconduct were reported since the last USMS DFR (if applicable)? L. How many criminal allegations of staff misconduct were reported since the last USMS DFR (if applicable)? NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipients} Any unauthorized review, use, disclosure, or distribution is prohibited If you are not the intended recipient, please contact the sender and destroy all copies of this document Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDBLAW ENFORCEMENT SENSITIVE (When Completed) Page 6 of 22 Form USM -218 Rev 07/21 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) How many criminal allegations of staff misconduct were reported to law enforcement since the last USMS DFR (if applicable)? Prisoner Anti -Discrimination Does the facility have a prisoner anti -discrimination policy that addresses: Age? C Yes C No Disability? C Yes C No Equal Pay/Compensation? C Yes C No Genetic Information? Yes C No Harassment? C Yes C No National Origin? C Yes C No Pregnancy? C Yes C No Race/Calor? C Yes C No Religion? C Yes C No Retaliation? C Yes C No Sex? C Yes C No Gender Identity? (' Yes C No Sexual Preference? C Yes C No Sexual Harassment? (' Yes C No Are services, programs, and activities provided to all eligible prisoners? ( Yes C No Prison Rape Elimination Act (PREA) Compliance Does the facility have a PREA compliance program? C Yes C No Does the program address the following items: Zero tolerance toward all forms of sexual abuse and sexual harassment? C Yes C No Prevention and response planning? C Yes C No Prisoner training and education? C Yes C No Employee training and education? C Yes C No Screening for risk of sexual victimization? C Yes C No Reporting and investigations? C Yes C No Discipline? C Yes C No Medical/ mental health care? C Yes C No Auditing? C Yes C No Corrective action? C Yes C No State compliance? C Yes C No Has the facility had an audit conducted by a DOJ certified PREA auditor within the past 3 years? C Yes C No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended rec#ent(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Page 7 of 22 Form USM -218 Rev. 07121 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) If 'No' to the previous question, has a DOJ PREA audit been scheduled? (— Yes (' No Scheduled DOJ PREA Audit Date Is a hard copy of the PREA audit available? i Yes (' No If 'Yes', Audit Date What was the name of the Auditor? Is there a corrective action plan in place? (' Yes (' No Has corrective action taken place? C Yes (, No Was the facility re -inspected to ensure the violations were corrected properly? C' Yes C No HEALTH CARE Intake and Screening Does the facility have policy or procedures for medical screening during intake? C, Yes C No Do all prisoners undergo medical screening during the initial intake process? (" Yes (— No If'No', how long after intake does the screening occur? months days Is a comprehensive health appraisal for each prisoner completed within 14 -days after initial intake? C Yes C, No If 'No', how long after intake does the appraisal occur? months days Does the facility ensure TB testing during the initial intake process? C Yes ( No If 'No', how long after intake does the TB test occur? months days Are TB test results provided to the USMS within 14 days? i Yes C' No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the'rntended recipient, please contact the sender and destroy all copies of this document Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to Federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Page 8 of 22 Form USM -218 Rev_ 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) If 'No', when were results provided? months days Do all prisoners undergo mental health screening during the initial intake process? (, Yes C No If 'No', how long after intake does the mental health screening occur? [� months days Do all prisoners undergo dental health screening during the initial intake process? C Yes C No If'No', how long after intake does the dental health screening occur? months days Are all medical screening results reviewed by a physician? C~ Yes (' No How long after intake does this occur? months clays Are medical screening records maintained for every prisoner? C` Yes (- No Medical, Dental, and Mental Health Does the facility have a medical unit staffed 2417? (- Yes (' No Does the facility employ an on-site mental health professional? C Yes (' No Are prisoners with mental health issues identified as part of the vulnerable population? C Yes C No Are prisoners with mental health issues referred to qualified mental health professionals? (, Yes (- No Routine, Chronic, and Emergency Health Services Are all prisoners made aware of the process for requesting health care services? C Yes r No Does the facility have a policy or procedures for identifying medical emergencies? (' Yes (1 No Does the facility provide access to prescription medication? C Yes (` No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipients) Any unauthorized review, use, disclosure, or distribution is prohibited If you are not the intended recipient. please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid In providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 9 of 22 Form USM -218 Rev 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Does the facility participate in the NMCC? C` Yes (' No Does the facility have an onsite pharmacy? (' Yes (1 No Does the facility document prisoner health care grievances? (' Yes i No Response to Medical, Mental and Dental Health Needs Are all prisoners who require health care beyond the capacity of the facility transferred to a facility where such care is available? (~ Yes (' No Are facility staff CPR/First Aid certified? (' Yes C' No With the exception of emergencies, does the facility use POD Medical Management to request approval for outside medical services? (' Yes (- No Does the facility immediately notify the district in the event of a USMS prisoner medical emergency? (' Yes (' No Suicide Prevention Does the facility have a suicide prevention program? C es (- No Does the facility document staff training for prisoner suicide prevention? C` Yes i No Does the facility have procedures for identifying prisoners at risk for suicide? (' Yes C' No Does the facility have procedures for monitoring prisoners at risk for suicide? (' Yes C` No How often are welfare inspections conducted on suicidal prisoners? elect... Does the facility report suicidal gestures, remarks, tendencies and attempts to the USMS? (~ Yes C No Does the facility provide mental health services to suicidal prisoners? (' Yes C' No Does the facility report restrictive housing of suicidal prisoners to the USMS? ( Yes (' No NOTICE This document Is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipieni(s). Any unauthorized review, use, disclosure. or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIED//LAW ENFORCEMENT SENSITIVE (When Completed) Page 10 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) How many suicidal prisoners were placed in restrictive housing during the rating period? Prisoner Death Does the facility have procedures to respond to a prisoner's death? C Yes C No Does the facility immediately notify the USMS in the event of a USMS prisoner death? C Yes C No Does the facility review each prisoner death? C Yes C No Infectious Disease Does the facility have policy or procedures to address the management and reporting diseases? C Yes C No Does the plan include: HIV? C Yes C No Tuberculosis? (' Yes C No Hepatitis? {` Yes C No Influenza? Yes C No Chlamydia? C Yes (' No COVID? C Yes C No Ebola? C" Yes C No HPV? C Yes C No Salmonella? C Yes C No Scabies? ( Yes C No Zika? C Yes (' No E. coli? C Yes C No Chicken Pox? C Yes C No Does the facility have an infectious and communicable disease policy or procedures to: Include identify prisoners with infectious and communicable diseases? C Yes (' No Treat prisoners with infectious and communicable diseases? C Yes C No Quarantine prisoners with infectious and communicable diseases? C Yes ( No Does the facility report all cases of infectious and communicable diseases to the USMS? C Yes C No Does the facility maintain adequate PPE for all staff in the event of a pandemic? C Yes C No and communicable NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s) Any unauthorized review. use, disclosure. or distribution is prohibited. If you are not the intended recipient. please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document Is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HiPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 11 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Does the facility maintain adequate PPE for all prisoners in the event of a pandemic? Yes C No SECURITY AND CONTROL Correctional Supervision Are correctional officer posts located in, or promptly to emergency situations? C Yes C No Are prisoners managed and supervised 2417? ' Yes (` No Security Features lately adjacent to, prisoner living areas so officers can respond Are weekly inspections of all security devices conducted? i Yes r No Security Inspections Does the facility conduct intermittent security sweeps of all areas prisoners occupy? (` Yes C No Searches and Contraband Does the facility have procedures for searching prisoners for contraband upon arrival to the facility? (' Yes C No Does the facility have procedures for searching prisoners for contraband prior to transporting the prisoner? (, Yes (^ No Does the facility have procedures for searching prisoners for contraband after prisoner visitation? (' Yes i No Does the facility have procedures for searching prisoners for contraband after work details? (` Yes C No Does the facility notify the USMS if a USMS prisoner is found with contraband? i Yes i No Prisoner Accountability and Supervision Does the facility have procedures for physically counting prisoners? C` Yes C No Number of counts per day NOTICE: Ti document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will he reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 12 of 22 Form USM -218 Rev. 07121 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Use of Force Does the facility have procedures for use of force? C Yes C No Does the facility document and report use of force? C Yes C No Does the facility investigate all use of force incidents? C Yes C No Non -routine Use of Restraints Does the facility have procedures for use of restraints? C Yes C No Is the use of restraints on pregnant or postpartum USMS prisoners reported to the USMS? C Yes C No Number of pregnant USMS prisoners since the last USMS DFR (if applicable). Number of times pregnant or postpartum USMS prisoners were restrained since the last USMS DFR (if applicable) Key Control Is the use of keys controlled and inventoried? C Yes C No Tools and Culinary Equipment Control Is the use of tools and culinary equipment controlled and inventoried? C Yes C No How many missing items during the rating period? Weapons Control Does the facility have procedures for the control and use of firearms and less -than -lethal devices? C Yes C No Prisoner Handbook and Discipline Do prisoners have 2417 access to a prisoner rule/handbook in English? C Yes C No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s) Any unauthorized review, use. disclosure. or distribution is prohibited. If you are not the intended recipient. please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HiPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDNLAW ENFORCEMENT SENSITIVE (When Completed) Page 13 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Does the English prisoner rule/handbook include facility rules and disciplinary procedures for violations? C Yes C No Do prisoners have 2417 access to a prisoner rule/handbook in Spanish? C Yes C No Does the Spanish prisoner rule/handbook include facility rules and disciplinary procedures for violations? C Yes C No Restrictive Housing Does the facility have written procedures for restrictive housing? C Yes C No Does the facility have written procedures for monitoring prisoners in restrictive housing? C Yes C No Does the facility immediately report restrictive housing of any USMS prisoner in the vulnerable population? C Yes C' No How many USMS prisoners in the vulnerable population were placed in restrictive housing since the last USMS DFR (if applicable)? Does the facility report restrictive housing of every USMS prisoner, monthly to the USMS? C Yes C No How many USMS prisoners were placed in restrictive housing since the last USMS DFR (if applicable)? How does the facility report restrictive housing to the USMS? ❑ Email ❑ Invoices ❑ Restrictive Housing Module Does the facility have procedures for reintegration of a prisoner from restrictive housing into the general population? C Yes C No Does the facility notify the prisoner of the reason for restrictive housing? C Yes C No Criminal Organization (If needed, use "Other Notes Section" on last page to document more than one organization.) Does the facility collect criminal organization or security threat group information? C Yes C No Name of Criminal Organization Cate o (Leave blank Or anization Level Leave blank) OID Leave blank I I - I F NOTICE This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document Any Protected Health Information contained in this document is to be used only to aid In providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 14 of 22 Form USM -218 Rev. 07121 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Remarks FOOD SERVICE Sanitation Requirements Has the facility been inspected by an external party within the past 12 months to ensure that the food service and equipment meets established health, sanitation, and safety protocols? C Yes C No If 'Yes', Date of Inspection Were any violations identified? C Yes C' No Have those violations been corrected? C Yes C No Was the facility re -inspected to ensure the violations were corrected properly? C Yes C No Adequate and Varied Meals Does the facility provide 3 meals per day? C Yes C No Does the facility provide a minimum of 2 hot meals per day? C Yes C No Does the facility provide meals that are nutritionally adequate and varied, as approved by a dietitian? C Yes C No Does the facility serve meals that match the approved meal menus? C Yes C No Does the facility provide special meals for prisoner religious or medical needs? C Yes C No SAFETY AND SANITATION Fire Safety Are annual fire safety inspections conducted by state or local fire officials? C Yes C No If'Yes', Date of Inspection NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sale use of the intended recipient(s) Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Page 15 of 22 Form USM -218 Rev. 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Were any violations identified? C Yes C No Have those violations been corrected? C' Yes C No Was the facility re -inspected to ensure the violations were corrected properly? C Yes C No Control of Dangerous Materials Does the facility have procedures for the maintenance, inventory, and storage of flammable, toxic, and caustic materials and chemicals? C Yes C No Does the facility have adequate personal protective equipment for the safe handling of chemicals? C Yes f No Does the facility receive training on the safe use of each chemical? C Yes (' No If yes to the above question, is the training documented? C Yes C No Clothing, Laundry and Bedding Are all prisoners issued at least two clean sets of temperature appropriate and properly sized clothing, to include uniforms, socks, underwear, t -shirts, braziers, and shoes? C Yes C No Do prisoners have access to laundry facilities, or the ability to have their clothing items washed? C Yes C No Do all prisoners receive adequate bedding, to include blanket, sheets, mattress and pillow? C Yes C No How often is bedding washed or exchanged? (Weekly, Every 2 weeks, Every 3 weeks, Monthly, Every other month, Never) Are exceptions to the laundry schedule made when clothes are soiled? C' Yes C No Are exceptions to the linen schedule made when linen and mattresses are soiled? C Yes C No Are mattresses a minimum of 12 inches from the floor? C Yes C No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure. or distribution is prohibited. If you are not the intended recipient. please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIED//LAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 16 of 22 Rev 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Housing Are single cells a minimum of 56 square feet? Yes (— No Are double cells a minimum of 72,5 square feet? (' Yes (, No Does the facility triple bunk or use boat beds? (- Yes (' No How many times did the facility triple bunk or use boat beds since the last USMS DFR (if applicable)? Personal Hygiene Are the following available at no cost: Soap? C Yes C' No Toothpaste? C` Yes i No Razors? C Yes f No Shampoo? (, Yes (' No Sanitary Napkins? C Yes C No Tampons? (— Yes C No Do all prisoners have 2417 access to an operable toilet? C' Yes (, No Do all prisoners have 2417 access to a washbasin with hot and cold running water? (, Yes (' No Physical Facility and Equipment Is the facility kept clean and in good repair? I Yes (' No Is all facility equipment in proper working order? (' Yes (' No Is there any evidence or sign of mold? C Yes (, No Is there any evidence or sign of insects? (' Yes C No Is there any evidence or sign of rodents? C Yes C' No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipients}. Any unauthorized review, use, disclosure. or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 17 of 22 Rev. 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Does the facility have adequate environmental controls to provide for indoor prisoner living conditions with air temperatures maintained between 69 and 76 degrees? C Yes C No SERVICE AND PROGRAMS Classification, Review, and Housing Does the facility have a procedure for prisoner classification, placement, and management? C Yes C' No Does the facility regularly review a prisoner's behavior or circumstances to determine housing placement? C Yes C No Are all USMS prisoners clearly identified in the facility's classification system? C Yes C No Copay and Fees Are prisoners charged a fee for haircuts? (' Yes C No If 'Yes', are all prisoners charged the same fee? (' Yes C No Are prisoners charged a fee for meals? C Yes C No If 'Yes', are all prisoners charged the same fee? C` Yes C No Are prisoners charged a fee for medical co -pay? C Yes C No If yes, are all prisoners charged the same fee? C Yes C No Religious Practices Do prisoners have the opportunity to participate in the religious practice of their faith? C Yes C No Volunteer Work Assignments Does the facility ensure that un -sentenced prisoners are not required to work unless they volunteer to do so? C Yes C No Does the facility pay prisoners for work? C Yes C No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient{s). Any unauthorized review, use, disclosure. or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 18 of 22 Rev. 07121 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Are USMS prisoners assigned to work outside of the secure perimeter of the facility? C Yes C No Does the facility document all USMS prisoner work assignments? C Yes C No Prisoner Grievance Program Is a grievance procedure that includes at least one level of appeal available to all prisoners? C Yes C No Juveniles Does the facility house juveniles? If 'No', move to next section. C Yes C No Does the facility have procedures for housing juveniles? C Yes C No Does the facility house prisoners between 18-21 who are charged as juveniles? C Yes C No Does the facility ensure the special diet, exercise, and education needs of juvenile prisoners are met? C Yes (' No Does the facility place prisoners under 21 who are charged as juveniles in restrictive housing? (' Yes C No Does the facility ensure that voluntary and involuntary restrictive housing of prisoners under 21 who are charged as juveniles are removed from restrictive housing every 3 hours? C Yes C No Does the facility immediately report juvenile segregation or restrictive housing of USMS juvenile prisoners? C Yes C No Exercise and Out -of -Cell Opportunities Does the facility provide prisoners with opportunity for exercise and out -of -cell time? C Yes C No Telephone Access Do prisoners have adequate access to telephones? (` Yes C No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure. or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 19 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Access to the Courts and Legal Materials Do prisoners have access to the courts? Yes (- No Do prisoners have access to legal material/law library? (` Yes (" No Access to Legal Representation Do the prisoners have confidential access to counsel via telephone? (— Yes (— No Do the prisoners have confidential access to counsel via written correspondence? (' Yes (' No Do the prisoners have confidential access to counsel via visitation? (' Yes (' No Visitation Does the facility have a prisoner visitation program? (— Yes ( No Does the prisoner visiting room have barriers to prevent contact visitation? (' Yes (' No NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL Information which is for the sole use of the intended recipient(s) Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 20 of 22 Form USM -218 Rev. 07/21 UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) CONCLUSION Other Notes NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s). Any unauthorized review, use, dlsciosure, or distribution is prohibited If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Form USM -218 Page 21 of 22 Rev. 07121 UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) Additional Points of Contact Title Name 1 71 Type of Contact Phone Number Extension Email Address Detention Facility Review (DFR) Certification I certify that this facility was inspected by an 0082 or 1811 with a current USM -222, Additional Duty Designation designating them as a Detention Facility Inspector and that applicable Corrective Action Recommendations were provided to the facility. Performed By Title Date NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information which is for the sole use of the intended recipient(s) Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIRAA Law and/or the Privacy Act and will be reported as such. UNCLASSIFIEDIILAW ENFORCEMENT SENSITIVE (When Completed) Page 22 of 22 Form USM -218 Rev. 07121