Master’s Level Mental Health Clinician -

The Berkshire County Sheriff’s Office, Jail & House of Correction has an immediate opening for full-time Master’s level Mental Health Clinician. Salary: $72,739.28/year. Position includes full state employee benefit package of life, health, dental and vision insurance, deferred compensation plan, membership in State Retirement System and generous paid leave plans. Online Employment Application available down below or may be picked up in our main lobby at 467 Cheshire Road, Pittsfield, MA., and returned to Diane Maynes, ADS, Berkshire County Sheriff’s Office, 467 Cheshire Road, Pittsfield, MA 01201. EOE/AA

Deadline for Applications: October 14th, 2024.

Application for Employment

IMPORTANT

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subjected to criminal penalties and civil liability. MGL Ch.149, Section 19B

FALSE OR INACCURATE INFORMATION OR THE OMISSION OF INFORMATION ON THIS APPLICATION WILL BE CAUSE FOR DISQUALIFICATION FOR EMPLOYMENT OR DISMISSAL AT ANY TIME AFTER EMPLOYMENT HAS COMMENCED.

This application will be kept on file for at least one year.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER It is the policy of the Berkshire County Sheriff’s Office to afford equal employment opportunity to all qualified persons regardless of race, color, religion, national origin, age, military status, sex, sexual orientation, disability, gender, genetic information, or veteran’s status except where age or sex is a bonafide occupational qualification as allowed by the Civil Rights Act of 1964.

Instructions for completing the application form

1. Type or print clearly in black or blue ink. 2. Answer every question fully and accurately even if you have submitted a résumé. If you cannot answer or do not understand any part of this application notify the Sheriff’s Office representative immediately. In addition to the information required below, please provide any other information you think would be helpful to us in considering you for employment. You may exclude all information indicative of any status in a protected category (age, race, religion, national origin, race, color, religious creed, national origin, sex, sexual orientation, genetic information, ancestry, marital status, veteran status or handicap). 3. The Commonwealth will review, if applicable: ◦ Criminal Offender Record Information (C.O.R.I) and; ◦ The Central Registry of Child Abuse/Neglect reports maintained in accordance with M.G.L. Chapter 119, Section 51 B. 4. If an offer of employment is made to you, the Commonwealth may identify that it is contingent upon the results of a medical exam and/or a tax and background check. 5. FALSE OR INACCURATE INFORMATION OR THE OMISSION OF INFORMATION ON THIS APPLICATION WILL BE CAUSE FOR DISQUALIFICATION FOR EMPLOYMENT OR DISMISSAL AT ANY TIME AFTER EMPLOYMENT HAS COMMENCED. 6. Read certification and releases carefully before signing. 7. Return completed and Signed application. ****(Must be a wet signature)**** 8. Incomplete applications will not be considered.

This application will be kept on file for at least one year.

PERSONAL INFORMATION

Prefix

Mr.

Ms.

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Street Address (If different than mailing)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you authorized to work in the U.S. on an unrestricted basis?(Required)

Yes

Are you over age 19?(Required)

Yes

EMPLOYMENT DESIRED

POSITION APPLIED FOR:(Required)

Date you can start(Required)

Berkshire County Sheriffs Office, 467 Cheshire Road, Pittsfield, MA 01201

Have you worked for the Commonwealth before?(Required)

Yes

Starting salary desired(Required)

Are you available for full time work?(Required)

Yes

Are you available for part time work?(Required)

Yes

Are you available to work nights and weekends?(Required)

Yes

In addition to your work history, what other experiences, skills or qualifications would qualify you for work with our agency?

Home Phone Number (with area code)(Required)

Business or Message

Email Address(Required)

National ID (Social Security Number)(Required)

Who referred you to us?(Required)

Agency

Employee

Newspaper Advertisement

Commonwealth Employment Opportunities (CEO)

Other

If referred by Other:

EDUCATION

First School

Name of School 1

School 1 Location (city and state)

School 1 Main Course of Study

Did you graduate from School 1?

Yes

Degree from School 1

Second School

Name of School 2

School 2 Location (city and state)

School 2 Main Course of Study

Did you graduate from School 2?

Yes

Degree from School 2

Third School

Name of School 3

School 3 Location (city and state)

Did you graduate from School 3?

Yes

Degree from School 3

Fourth School

Name of School 4

School 4 Location (city and state)

School 4 Main Course of Study

Did you graduate from School 4?

Yes

Degree from School 4

List any additional education or training:

PROFESSIONAL REFERENCES (not personal): List 3 people not related to you who can comment on your work

First Professional Reference

Name (Professional Reference 1)

Address (Professional Reference 1)

Occupation (Professional Reference 1)

Phone Number (with area code) Professional Reference 1

Years Acquainted (Professional Reference 1)

Second Professional Reference

Name (Professional Reference 2)

Address (Professional Reference 2)

Occupation (Professional Reference 2)

Phone Number (with area code) Professional Reference 2

Years Acquainted (Professional Reference 2)

Third Professional Reference

Name (Professional Reference 3)

Address (Professional Reference 3)

Occupation (Professional Reference 3)

Phone Number (with area code) Professional Reference 3

Years Acquainted (Professional Reference 3)

PERSONAL REFERENCES (not professional): List 3 people not related to you who can comment on your work performance.

First Personal Reference

Name (Personal Reference 1)

Address (Personal Reference 1)

Occupation (Personal Reference 1)

Years Acquainted (Personal Reference 1)

Second Personal Reference

Name (Personal Reference 2)

Address (Personal Reference 2)

Occupation (Personal Reference 2)

Phone Number (with area code) Personal Reference 2

Years Acquainted (Personal Reference 2)

Third Personal Reference

Name (Personal Reference 3)

Address (Personal Reference 3)

Occupation (Personal Reference 3)

Phone Number (with area code) Personal Reference 3

Years Acquainted (Personal Reference 3)

MILITARY SERVICE INFORMATION This information is furnished on a voluntarybasis.

Check all that apply to you:

Veteran

Disabled Veteran

Vietnam Era Veteran

Dates of Service:

Dates of Service From

Dates of Service To

Branch of Service

If Vietnam Era Veteran, have you been certified by the State Office of Affirmative Action?

Yes

If yes, what is the Certification #?

(Please attach Form DD214 or a copy of SOAA certification.)

IMMEDIATE FAMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT Per Executive Order 444, please disclose any immediate family members, including those related to your immediate family by marriage, who are employed by the Commonwealth of Massachusetts. You are required to complete the information below. “Immediate family” is defined as a spouse, child, parent, and sibling; and the spouse’s child, parent and sibling. Include those employed in all branches of state government: judicial, legislative, executive, higher education and state authorities; and those employed as regular or contract employees, or elected officials. This "sunshine disclosure" is intended to ensure that the citizens of our Commonwealth have full confidence in their government and its hiring process. The disclosure will not be used to exclude any qualified applicant seeking a position within the Executive Branch from receiving full consideration based on the merits of his/her credentials and the requirements of the job. Attach additional pages if needed.

RELATIVE 1

Name of Relative 1

Relationship (Relative 1)

Title of Relative's Job (Relative 1)

State Agency (Relative 1)

RELATIVE 2

Name of Relative 2

Relationship (Relative 2)

Title of Relative's Job (Relative 2)

State Agency (Relative 2)

RELATIVE 3

Name of Relative 3

Relationship (Relative 3)

Title of Relative's Job (Relative 3)

State Agency (Relative 3)

RELATIVE 4

Name of Relative 4

Relationship (Relative 4)

Title of Relative's Job (Relative 4)

State Agency (Relative 4)

RELATIVE 5

Name of Relative 5

Relationship (Relative 5)

Title of Relative's Job (Relative 5)

State Agency (Relative 5)

Employment History

COMPLETE ALL INFORMATION IN FULL
(A resume may not be substituted but may be included as a supplement)

Begin with your most recent employment, including any present employment. Your present employer will not be contacted without your permission. You may include any verifiable work performed on a volunteer basis. Any gaps in employment must be explained.

Are you employed right now?(Required)

Yes

Most Recent:

Company Name (Most Recent Employer)

Phone Number (with area code) Most Recent Employer

Address (Most Recent Employer)

City State / Province / Region ZIP / Postal Code

Job Title (Most Recent Employer)

Supervisor (Most Recent Employer)

(Most Recent Employer) From:

(Most Recent Employer) Until:

Specific Duties (Most Recent Employer)

Reason for Leaving (Most Recent Employer)

Second Most Recent:

Company Name (2nd Most Recent Employer)

Telephone (2nd Most Recent Employer)

Address (2nd Most Recent Employer)

City State / Province / Region ZIP / Postal Code

Job Title (2nd Most Recent Employer)

Supervisor (2nd Most Recent Employer)

(2nd Most Recent Employer) From:

(2nd Most Recent Employer) Until:

Specific Duties (2nd Most Recent Employer)

Reason for Leaving (2nd Most Recent Employer)

Third Most Recent:

Company Name (3rd Most Recent Employer)

Phone Number (with area code) 3rd Most Recent Employer

Address (3rd Most Recent Employer)

City State / Province / Region ZIP / Postal Code

Job Title (3rd Most Recent Employer)

Supervisor (3rd Most Recent Employer)

(3rd Most Recent Employer) From:

(3rd Most Recent Employer)Until:

Specific Duties (3rd Most Recent Employer)

Reason for Leaving (3rd Most Recent Employer)

Fourth Most Recent:

Company Name (4th Most Recent Employer)

Phone Number (with area code) 4th Most Recent Employer

Address (4th Most Recent Employer)

City State / Province / Region ZIP / Postal Code

Job Title (4th Most Recent Employer)

Supervisor (4th Most Recent Employer)

(4th Most Recent Employer) From:

(4th Most Recent Employer) Until:

Specific Duties (4th Most Recent Employer)

Reason for Leaving (4th Most Recent Employer)

If you need to submit more employers, please keep to the information requested for each and upload a file:

Max. file size: 50 MB.

If you wish to upload a resume, please do so here:

Max. file size: 50 MB.

Has any of the following happened to you in the last ten (10) years:

1 - Fired from job
2 - Quit a job after being told you would be fired
3 - Left a job by mutual agreement following allegations of misconduct
4 - Left a job by mutual agreement following allegations of unsatisfactory performance
5 - Left a job for other reasons under unfavorable circumstances.

If yes - use the numbers above under “code” to explain the reason your employment was ended.

Leaving 1

(Left employment 1) Date (month/year)

(Left employment 1) Code:

(Left employment 1) Employer’s Name & Address

Leaving 2

(Left employment 2) Date (month/year)

(Left employment 2) Code:

(Left employment 2) Employer’s Name & Address

Leaving 3

(Left employment 3) Date (month/year)

(Left employment 3) Code:

(Left employment 3) Employer’s Name & Address

Leaving 4

(Left employment 4) Date (month/year)

(Left employment 4) Code:

(Left employment 4) Employer’s Name & Address

Leaving 5

(Left employment 5) Date (month/year)

(Left employment 5) Code:

(Left employment 5) Employer’s Name & Address

Leaving 6

(Left employment 6) Date (month/year)

(Left employment 6) Code:

(Left employment 6) Employer’s Name & Address

If yes – begin with the most recent occurrence and go backwards, providing date fired, quit or left and Employer identity, and a detailed explanation for each instance. Use additional sheets of paper if necessary.

Employment Leaving 1

Employment Leaving 2

Employment Leaving 3

Employment Leaving 4

Employment Leaving 5

If additional quits, fireds, leifts, please upload:

Max. file size: 50 MB.

RELEASE AND CERTIFICATION PLEASE READ BEFORE SIGNING

I understand that the foregoing will be verified in order to expedite my application for employment with the Berkshire County Sheriff’s Office.

I hereby authorize the Berkshire County Sheriff’s Office to conduct a full investigation into my background.

I authorize the Berkshire County Sheriff’s Office to obtain my previous work records, employment records, character references and any other information concerning character, ability and habits and all other necessary information. Further I grant authority to the keeper of these records to release said records to the Berkshire County Sheriff’s Office for the purpose of making its hiring decision.

I agree that the Berkshire County Sheriff’s Office shall not be liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statement, omissions or answers made by me on this application.

I agree that my previous employers shall not be liable with regard to any information provided by them in connection with this release.

I certify under the pains and penalty of perjury that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably.

I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.

In compliance with the Immigration and Reform and Control Act of 1986, I understand that I will be required to provide approved documentation that verifies my right to work in the United States on my first day of employment. I have received the list of approved documents with this application.

I understand that unless I am subject to the terms of a collective bargaining agreement providing otherwise, my employment will be at-will, which means that both the Berkshire County Sheriff’s Office and I are free to terminate the employment relationship at any time for any non-statutorily prohibited reason or for no reason at all, with or without notice.

I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.

___+++

Release and Certification Consent(Required)

I agree to the below

I understand that the foregoing will be verified in order to expedite my application for employment with the Berkshire County Sheriff’s Office.

I hereby authorize the Berkshire County Sheriff’s Office to conduct a full investigation into my background.

I agree that my previous employers shall not be liable with regard to any information provided by them in connection with this release.

I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.

I hereby acknowledge that I have read in full and understand the above statements and conditions of employment.

Name(Required)

First Last

Applicant Signature

Date(Required)

I understand that typing my name in the box above constitutes a legal signature confirming that I acknowledge and agree to the above Terms. Signatories have the option to opt out and sign with a paper signature instead.

MISCELLANEOUS JOB-RELATED INFORMATION

Job Interest

Shift Preferred(Required)

1st (Days)

2nd (Evenings)

3rd (approx. 11:00pm –7:00am)

Are you available to work EVERY Saturday and Sunday?(Required)

Yes

No

Certificates and Licenses
List any professional licenses, registrations or certifications you possess:

License 1:

(Cert/License 1) License

(Cert/License 1) License Number

(Cert/License 1) Date Issued
MM slash DD slash YYYY

(Cert/License 1) Date Expires
MM slash DD slash YYYY

License 2:

(Cert/License 2) License

(Cert/License 2) License Number

(Cert/License 2) Date Issued
MM slash DD slash YYYY

(Cert/License 2) Date Expires
MM slash DD slash YYYY

License 3:

(Cert/License 3) License

(Cert/License 3) License Number

(Cert/License 3) Date Issued
MM slash DD slash YYYY

(Cert/License 3) Date Expires
MM slash DD slash YYYY

English Language

Describe your proficiency in the english language:

(English Language) Simple Conversation:(Required)

Yes

No

(English Language)Simple Reading:(Required)

Yes

No

(English Language) Read and Speak Fluently:(Required)

Yes

No

Language Capabilities

List any language(s) other than English in which you are proficient including Sign Language and ability to read Braille.

(Lang. A) Language

(Lang. A) Conversational

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. A) Reading

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. A) Writing

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. B) Language

(Lang. B) Conversational

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. B) Reading

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. B) Writing

HIGH (Fluent)

MOD (Good)

LOW (Fair)

Language

(Lang. C) Conversational

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. C) Reading

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. C) Writing

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. D) Language

(Lang. D) Conversational

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. D) Reading

HIGH (Fluent)

MOD (Good)

LOW (Fair)

(Lang. D) Writing

HIGH (Fluent)

MOD (Good)

LOW (Fair)

* If language proficiency is required, the Commonwealth may administer a Bilingual Certification Examination.

IN CASE OF EMERGENCY, PLEASE NOTIFY

Name(Required)

Relationship(Required)

Phone Number (with are code)(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Criminal Offender Record Information (C.O.R.I) PLEASE READ BEFORE SIGNING

C.O.R.I Consent Date(Required)
MM slash DD slash YYYY

C.O.R.I Consent Name(Required)
First Last

C.O.R.I Consent Print Name Again

PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING NOTICE PLEASE READ BEFORE SIGNING

PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING Consent Date(Required)
MM slash DD slash YYYY

PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING Consent Name(Required)
First Last

PRE-EMPLOYMENT PHYSICAL & DRUG SCREENING Consent Print Name Again

IMMIGRATION REFORM AND CONTROL ACT REQUIREMENT

In compliance with the Immigration and Reform and Control Act of 1986, you will be required to provide approved documentation that verifies your right to work in the United States prior to beginning work here at this agency. Please be prepared to provide any of the following documentation if you are offered and accept a position with us:

Any one of the following: (These establish both identity and employment authorization)

1. U.S. Passport

2. Certificate of U.S. citizenship (issued by Immigration & Naturalization Service)

3. Certificate of Naturalization (issued by INS)

4. Current foreign passport with valid endorsement authorizing employment

5. Resident alien card or other alien registration card, with photo or other approved identifying information, which evidences employment authorization

OR one from List A and one from List B:

LIST A These establish employment authorization:

1. Social Security Card (unless it specifies that it does not authorize employment)

2. Certificate of U.S. birth or other documentation which establishes U.S. nationality or birth

3. Other approved documentation

LIST B These establish identity:

1. Driver’s license or similar state I.D. card with photo or other approved identifying information

2. Other approved documentation of identity for applicants under age 16 or from a state which does not issue an I.D. card (other than a driver’s license)

THIS VERIFICATION PROCESS IS REQUIRED FOR ALL EMPLOYEES HIRED ON OR AFTER NOVEMBER 6, 1986.

CORRECTIONAL OFFICER – ESSENTIAL FUNCTIONS

1. Regular, punctual and predictable attendance at assigned workplace and post.

2. Maintaining custodial care and control of inmates by escorting or transporting them under restraint; patrolling facility (including two –tiered areas with approximately fifteen stairs); making periodic rounds, head counts and security checks of buildings, grounds and inmate quarters; monitoring inmates movements and whereabouts; and guarding and directing inmates during work assignment to maintain order and security in a correctional institution.

3. Knowing, complying with and enforcing departmental policies and security procedures;

4. Obeying moderately complex oral and written orders;

5. Observing inmate and staff activity in person and in closed circuit monitors;

6. Searching cells, footlockers and other areas;

7. Frisking inmates and performing strip searches;

8. Listening for possible disturbances;

9. Maintaining inmate counts, making accurate written entries in log books and preparing accurate written reports;

10. Opening and closing doors and gates manually and electronically;

11. Communicating orally

12. Using communication, emergency and other equipment

13. Applying handcuffs, other restraints, and safety devices;

14. Performing restraining and self-defense techniques;

15. Lifting emergency equipment (e.g. fire extinguisher) and performing assisted lifting of inmates; rendering first aid when necessary

16. Participating in training;

17. Dealing effectively with inmates one-on-one and in large groups; using IPC skills and de-escalation techniques

18. Dealing calmly and effectively with stressful situations, including emergencies;

19. Exercising good judgment;

20. Carrying and discharging a firearm;

21. Operating a motor vehicle;

22. Performing computer assisted work;

23. Lifting more than 50 pounds;

24. Working outdoors in all types of weather;

25. Any and all other duties as assigned at any time.

The Sheriff reserves the right to modify these job responsibilities as may be appropriate from time to time.

ENTRANCE REQUIREMENTS Consent Date(Required)
MM slash DD slash YYYY

ENTRANCE REQUIREMENTS Consent Name(Required)
First Last

ENTRANCE REQUIREMENTS Consent Print Name Again

Name(Required)
First Middle Last

Print Name Again

Authorization for Release of Information Agreement

Authorization for Release of Information Agreement Consent(Required)
I hereby acknowledge that I have read in full and understand the below statement.
Authorization for Release of Information Agreement

TO WHOM IT MAY CONCERN: I am an applicant for a position with the Berkshire County Sheriff’s Office, Jail and House of Correction. The Sheriff’s Office needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I have applied. It is in the public’s interest that all relevant information concerning my personal and employment history be disclosed to the Berkshire County Sheriff’s Office.

I hereby authorize any representative of the Berkshire County Sheriff’s Office bearing this release to obtain any and all information in pertaining to my employment and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof concerning myself by and to any duly authorized agent of the Berkshire County Sheriff’s Office, whether said records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure.

I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the specific purpose of pursuing a background investigation that may provide pertinent data for the Sheriff’s Office to consider in determining my suitability for employment in that agency. It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.

I consent to your release of any and all public and private information that you may have concerning me, my work record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest, unless said files are sealed by a court order.

I hereby release you, your organization, and all others from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I hereby release you, as the custodian of such records, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information or any attempt to comply with it. I direct you to release such information upon request of the duly authorized representative of the Berkshire County Sheriff’s Office regardless of any agreement I may have made with you previously to the contrary.

For and in consideration of the Berkshire County Sheriff’s Office acceptance and processing of my application for employment, I agree to hold the Commonwealth of Massachusetts, the County of Berkshire, the Berkshire County Sheriff’s Office, and all of their officers, agents, employees, representatives and insurers harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the Berkshire County Sheriff’s Office. I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.

I understand that my rights under title 5, United States Code, Section 552a. the Privacy Act of 1974, with regard to access and to disclosure of records, and I waive those rights with the understanding that information furnished will be used by the Berkshire County Sheriff’s Office in conjunction with employment procedures.

A photocopy or FAX copy of this release form will be valid as an original thereof, even though the said photocopy or FAX copy does not contain an original writing of my signature.

A) this waiver is valid for a period of two years from the date of my signature.

B) Should there be any questions as to the validity of this release, you may contact me at the address listed on this form.

C) I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form.

D) I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and against all claims, damages, losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request.

Authorization for Release of Information Agreement Consent Date(Required)
MM slash DD slash YYYY

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number (with area code)(Required)

National ID (Social Security Number)

MA Driver’s License No. (required)(Required)

AFFIRMATIVE ACTION DATA RECORD CONFIDENTIAL

The Berkshire County Sheriff’s Office is committed, in spirit as well as in action, to abide by all laws dealing with equal employment opportunity. It is our policy to guarantee equal employment opportunities for all qualified persons without regard to their age, race, creed, color, national origin, ancestry, marital status, gender, military status, sex, sexual orientation, military status, genetic information or disability, which can be reasonably accommodated.

Further, the Berkshire County Sheriff’s Office will act in good faith, to affirmatively recruit and consider for promotion individuals in protected categories. Age, race, creed, color, national origin, ancestry, marital status, gender, military status, sex, sexual orientation, genetic information or disability are not factors in employment, promotion, transfer, compensation, lay-off, discipline and termination.

In order to effectively monitor the success of our recruitment and employment efforts, it is requested that you provide the following information.

The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Affirmative Action Data Records are kept in a confidential file and are not a part of your application for employment or your personnel file. Your cooperation is voluntary. Inclusion or exclusion of any affirmative action data will not jeopardize or adversely affect any employment decision.

Name(Required)
First Middle Last

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number (with area code)(Required)

Phone 2

National ID (Social Security Number)

Untitled(Required)

Male

Female

Check one of the following: (Race)

White

Black

Hispanic

Asian/Pacific Islander

Native American (American Indian or Alaskan Native)

(If Native American, please attach documentation of tribal affiliation)
Max. file size: 50 MB.

Check if the following is applicable:
Vietnam Era Veteran* (Ninety (90) days of active duty service, any part of which occurred between August 5, 1964 and May 7, 1975)

*In order to qualify for Affirmative Action status as a Vietnam Era Veteran, you must apply for Eligibility Certification that is issued by the State Office of Affirmative Action. Forms are available from the State Office of Affirmative Action, (617) 727-7441.

Check if the following is applicable:
Person with a disability* A disability means a physical or mental impairment with substantially limits one or more major life activities; a record of such impairment; or being regarded as having such an impairment. (“Major Life Activities” includes but is not limited to functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working. Information on disability is maintained by the ADA Coordinator and is not shared with Human Resources.)

*If you wish to obtain Affirmative Action status as a Person with a Disability after you have been employed by this agency you may need to submit self-identification and verification of such with the ADA Coordinator if your disability is not obvious. Appropriate forms are available from this agency’s ADA Coordinator.

Wish to obtain Affirmative Action status as a Person with a Disability Name
First Last

Wish to obtain Affirmative Action status as a Person with a Disability Please Re-type your name as signature

Wish to obtain Affirmative Action status as a Person with a Disability Date
MM slash DD slash YYYY

PREA National Standards - 28 CFR § 115.17 Hiring and promotion decisions:

(a) The agency shall not hire or promote anyone who may have contact with inmates, and shall not enlist the services of any contractor who may have contact with inmates, who—

(1) Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997);

(2) Has been convicted 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; or

(3) Has been civilly or administratively adjudicated to have engaged in the activity described in paragraph (a)(2) of this section.

(b) The agency shall consider any incidents of sexual harassment in determining whether to hire or promote anyone, or to enlist the services of any contractor, who may have contact with inmates.

(c) Before hiring new employees who may have contact with inmates, the agency shall:

(1) Perform a criminal background records check; and

(2) Consistent with Federal, State, and local law, make its best efforts to contact all prior institutional employers for information on substantiated allegations of sexual abuse or any resignation during a pending investigation of an allegation of sexual abuse.

(d) The agency shall also perform a criminal background records check before enlisting the services of any contractor who may have contact with inmates.

(e) The agency shall either conduct criminal background records checks at least every five years of current employees and contractors who may have contact with inmates or have in place a system for otherwise capturing such information for current employees.

(f) The agency shall ask all applicants and employees who may have contact with inmates directly about previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring or promotions and in any interviews or written self-evaluations conducted as part of reviews of current employees. The agency shall also impose upon employees a continuing affirmative duty to disclose any such misconduct.

(g) Material omissions regarding such misconduct, or the provision of materially false information, shall be grounds for termination.

PREA Inquiries

In accordance with National Standards to Prevent, Detect and Respond to Prison Rape, 28 CFR § 115.17, a correctional facility must make the following inquiries of any applicant for employment in a position that may have contact with inmates and all contractors who may have contact with inmates. In accordance with 28 CFR § 115.17 (g), any material omission in answering the following questions or the provision of materially false information, shall be grounds for disqualification or for termination if discovered after hire.

1. Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility or other “institution” within the meaning of 42 U.S.C. 1997(1) (to include State facilities for persons who are mentally ill, disabled, or retarded, or chronically ill or handicapped; residential care or treatment facilities for juveniles; and facilities that provide skilled nursing, intermediate or long-term care, or custodial or residential care)? Choose One:(Required)

Yes

No