Visiting Questionnaire Template

Visiting Questionnaire Template

The Visiting Questionnaire form, officially designated as CDC 106, is a document utilized by the California Department of Corrections to assess an individual's eligibility to visit an inmate. This form collects essential information about the visitor and the inmate, ensuring compliance with institutional regulations and security protocols. To begin the process of visiting an inmate, please fill out the form by clicking the button below.

Table of Contents

The Visiting Questionnaire form is a crucial document for anyone wishing to visit an inmate within the California Department of Corrections. This form collects essential information that helps officials assess whether a visitor is eligible to enter the facility. It requires details such as the inmate's name and CDC number, the visitor's personal information, and their relationship to the inmate. Visitors must also disclose any previous visits to other inmates, criminal history, and current legal statuses, including probation or parole. Additionally, the form addresses special considerations for visitors with disabilities, ensuring that accommodations can be made as needed. Importantly, the questionnaire emphasizes the importance of accuracy, as any omissions or false information can lead to disapproval of the visit. Once completed, the form must be mailed directly to the visiting office of the institution where the inmate is housed. Understanding the requirements and implications of this form is vital for anyone looking to maintain connections with loved ones in the correctional system.

Visiting Questionnaire Sample

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS

VISITING QUESTIONNAIRE

CDC 106 (Rev. 01/03)

READ CAREFULLY. Please PRINT or TYPE. The information requested will be used by officials of the California Department of Corrections (CDC) to determine whether your questionnaire will be approved or disapproved. The information provided will be maintained in a file pertaining to the inmate.

In accordance with the Privacy Act of 1974 (PL93-579), providing your Social Security number is optional. However, any omission or falsification on this questionnaire may be cause for denial of visiting. Please mail this form directly to the visiting office of the institution where the inmate is confined.

1. NAME OF INMATE YOU WANT TO VISIT (LASTFIRSTMIDDLE)INMATE’S CDC NUMBER

2. YOUR NAME (Print your name exactly as indicated on the photo identification you will he using)

SUFFIX (Jr., Sr., etc.)

HOME TELEPHONE NUMBER

 

 

 

 

 

 

 

 

( )

 

3. MAIDEN NAME (If applicable)

HAVE YOU EVER USED ANOTHER NAME? IF SO, PLEASE LIST

RELATIONSHIP TO INMATE: (Spouse, Son/Daughter, other)

4. DATE OF BIRTH (Mo/Day/Yr)

GENDER (Check one)

BIRTHPLACE (City

County

State

Country)

 

MALE FEMALE

 

 

 

 

 

 

5. ID NUMBER

ID TYPE (Check one) q DR1VERS LICENSE

 

 

STATE ID

MILITARY ID

 

 

 

USINS CARD

 

 

MCAS

PASSPORT

 

OFFICIAL USE ONLY

ISSUED BY (County

 

Slate

 

 

Country)

 

6. SOCIAL SECURITY NUMBER

EXPIRATION DATE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. CURRENT RESIDENCE ADDRESS: STREET ADDRESS Apt. ft (If Aplicable)

 

 

CITY

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

8. MAILING ADDRESS: (If different from Residence Address)

 

 

 

 

CITY

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

9. PREVIOUS ADDRESS WITHIN PAST TWO YEARS: Apt. ft (If Applicable)

 

 

CITY

 

STATE

ZIP CODE

 

 

 

 

 

 

 

10. ACCOMPANYING MINOR(S) (If Any): NAME, DOB, RELATIONSHIP TO INMATE

 

 

 

 

1. 2.

 

 

 

 

 

 

3.

 

 

10. Continued

 

 

 

 

 

 

 

 

 

4.

 

5.

 

 

 

6.

 

 

11. HAVE YOU EVER VISITED ANOTHER INMATE(S) IN A CALIFORNIA PRISON?

 

 

 

(Check one) YES

 

O NO

If YES, complete Item 11 A. Attach additional sheet(s) if more than two inmates.

 

 

 

 

 

 

 

11 A. INMATE NAME

 

 

CDC NUMBER

 

INSTITUTION WHERE YOU VISIT INMATE

RELATIONSHIP TO INMATE

I.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. HAVE YOU EVER BEEN DETAINED, ARRESTEQ,©XCONVICTED OF A CRIME? If YES, complete Item 12A. List all detentions, arrest and/or convictions. Failure to list all requested

 

 

(Check one) Q YES

NO

 

 

information may .result jn-denial of visiting. Attach additional sheet(s) if necessary.

 

 

 

 

 

 

 

 

 

 

 

 

12A. OFFENSE

 

 

 

APPROX. DATE

DISPOSITION: (Dismissed, Probation, Jail, Prison)

 

COUNTY

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. ARE YOU ON PROBATION?

ARE YOU ON PAROLE OR CIVIL

HAVE YOU BEEN INCARCERATED IN A STATE

 

14. ARE YOU CURRENTLY UNDER ANY TYPE OF COURT

(Check one) QygS

NO

ADDICT OUTPATIENT STATUS?

ADULT/JUVENILE CORRECTIONAL FACILITY?

 

IMPOSED PROGRAM? (Check one) Q YES

NO

 

 

 

(Check one) Q YES

NO

(Check one)

Q YES

NO

 

if YES, please explain on additional sheet and attach to this form.

If YES, answer 13 A.

 

 

If YES, answer 13A.

 

 

 

If YES, read 13B

 

 

 

 

 

 

 

 

 

 

 

 

13A. TYPE: (Court, Formal,

 

SUPERVISING AGENCY

NAME, ADDRESS, AND TELEPHONE NUMBER OF YOUR PROBATION/PAROLE

COUNTY

STATE

Informal, etc.)

 

 

OFFICER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13B. If you were discharged from an institution or discharged from parole or outpatient status within the last twelve (12) months, you must have prior written approval of the Warden before visiting will be permitted. You will also need to provide a copy of your discharge paperwork.

CONrCWlED ON BACK PAGE

15.If you are under 18 years of age and are not an emancipated minor or the inmate’s legal spouse, you must have the written notarized consent of a parent or legal guardian and be accompanied by a responsible adult who is also approved to visit. The notarized written consent must be presented each time a minor visits unless prior approval has been attained form the Warden for an inmate to visit with his or her unchaperoned children.

16.VISITORS WITH DISABILITIES: If you have special requirements related to your disability (medical implants, prosthetic devices or requiring

mobility assistive devices, i.e.,. crutches, walkers, braces, wheelchairs, battery operated or custom prescribed wheelchairs, guide dog for the visually or hearing impaired, insulin kit with syringes, etc.) you will need to attach a verifying statement from your physician. Visitors with guide dogs will need to provide the dog’s certification paperwork upon visit check-in. The CDC will make every effort to provide reasonable accommodations for all qualified/eligible visitors with disabilities in keeping with the safety and security of the institution and the public. If you have any questions and/or concerns, please contact the institution where the inmate is confined.

17.The following laws relate to prison visitation:

SUBJECT TO SEARCH: Visitors entering the correctional institution, camp or facility grounds are subject to a search of their person, vehicle and property. Except as described below, visitors may leave the institution, camp, or facility grounds rather than submit to a search of their person, vehicle or property. Refusal to submit to the search will result in denial of visiting for that day.

Visitors may not elect to leave the correctional institution, camp or facility grounds rather than submit to a search when institution officials possess a court issued search warrant or cause for a search arises while the visitor is on the institution grounds and the cause for the search is believed by institutional officials to be a criminal offense.

FIREARMS AND DRUGS ON INSTITUTIONAL GROUNDS /ASSISTING INMATES TO ESCAPE: It is a felony for anyone to assist inmates to escape. Bringing firearms, deadly weapons, explosives, tear gas, drugs, drug paraphernalia, or selling drugs on prison grounds, or giving/selling inmates firearms, weapons, explosives, liquor, cocaine, or other narcotics or any kind of drugs, including marijuana, is a crime (Sections 2772, 2790,4534, 4535, 4550, 4573, 4573.5, 4573.6, 4573.8, 4573.9, 4574, 4600, California Penal Code).

GIVING LETTERS TO INMATES OR TAKING LETTERS OUT FOR INMATES BY ANYONE IS A MISDEMEANOR: (Section 4570, 4570.1, California Penal Code).

FALSE IDENTIFICATION: Anyone who falsely identifies himself/herself to gain admittance to a prison is guilty of a misdemeanor. Persons previously convicted of a felony in the State who come upon the grounds of a prison without permission of the official in charge are guilty of a felony (Section 4570.5, 4571 California Penal Code).

TRESPASSING: Entry on institution property for unauthorized purposes will be considered trespassing as provided in Section 602(j) of the California Penal Code. Refusal or failure to leave the property when requested to do so by an official will be considered trespassing as provided in Section 602(p) of the California Penal Code.

PERIOD OF EMERGENCY: In the event of an emergency situation that affects a significant portion of the inmate population at an institution, the visiting program and other program activities may be suspended during the period of emergency (Section 2601(d), California Penal Code).

GIVING OR RECEIVING GIFTS: Giving or receiving gifts to or from inmates is a misdemeanor (Section 2540, 2541, California Penal Code).

HOSTAGES: Hostages will not be recognized for bargaining purposes during attempted escapes by inmates (Section 3304, California Code of Regulations, Title 15, Division 3, Chaper 1).

18. If you are APPROVED to visit, the inmate will be notified and it is his/her responsibility to notify you.

If you are DISAPPROVED to visit, the institution will notify you by mail. You will not be allowed to visit until your application is approved.

I have read and understand the above information and agree to follow all

Federal, State and CDC rules and regulations.

VERIFICATION OF MAILING

I have mailed this Visiting Questionnaire to the visitor applicant.

VISITOR SIGNATURE

DATE

inmate;/£i6nature / cdc #

date

|

OFFICIAL USE ONLY-TO BE COMPLETED BY INSTITUTION STAFF

 

APPROVED

----------------------------------------------------------------------------------Criminal History:

O NO O YES CII/FBI #

.

 

 

 

DISAPPROVED, for the following reason(s):

 

(If DISAPPROVED, the applicant and inmate are to be informed in writing of the disapproval.)

Omissions and/or falsifications Section(s):

 

 

Need copy of Declaration of Discharge

 

 

Need

 

disposition(s)

for:

Applicant is under:

parole

formal probation

Civil Addict Outpatient supervision

Arrest record received via DOJ indicates applicant has an extensive and /or recent history of criminal activity for offenses that are particulary sensitive to the institutional security. May reapply after: (DATE:)

Applicant’s privileges to visit will be reconsidered:

 

 

 

 

 

upon receipt of the above requested information

and/or

after (DATE:

)

 

 

 

 

 

 

 

 

PRINT NAME

 

SIGNATURE

 

TITLE

INSTITUTION

DATE

 

 

 

 

 

 

 

INMATE/V1S1TOR NOTIFIED ON (DATE)

BY WHOM

Document Attributes

Fact Name Description
Form Title Visiting Questionnaire form, CDC 106
State California
Governing Law Privacy Act of 1974 (PL93-579)
Purpose To determine if a visitor's request to visit an inmate will be approved or disapproved.
Social Security Number Providing your Social Security number is optional, but omission may lead to denial of visiting.
Mailing Instructions The completed form must be mailed directly to the visiting office of the institution where the inmate is confined.
Visitor Requirements Minors require notarized consent from a parent or legal guardian and must be accompanied by an approved adult.
Search Policy Visitors are subject to search upon entering the facility. Refusal to submit to a search will result in denial of visiting.

Visiting Questionnaire: Usage Instruction

Completing the Visiting Questionnaire form is a straightforward process. This form gathers essential information to facilitate the visiting process for inmates in California correctional facilities. Once the form is filled out accurately, it should be mailed directly to the institution where the inmate is located. Follow the steps below to ensure all necessary information is provided correctly.

  1. Inmate Information: Enter the inmate's full name (last, first, middle) and their CDC number in the designated fields.
  2. Your Information: Write your name exactly as it appears on your photo identification. Include any suffix (e.g., Jr., Sr.) and your home telephone number.
  3. Maiden Name: If applicable, provide your maiden name and list any other names you have used.
  4. Relationship: Specify your relationship to the inmate (e.g., spouse, son/daughter).
  5. Date of Birth: Fill in your date of birth, gender, and birthplace (city, county, state, country).
  6. ID Information: Indicate your ID number and type (e.g., driver’s license, state ID). Mention the issuing authority.
  7. Social Security Number: Provide your Social Security number if you choose to do so, and include the expiration date of your ID.
  8. Current Residence: Fill out your current address, including street address, apartment number (if applicable), city, state, and ZIP code.
  9. Mailing Address: If different from your residence, provide your mailing address, including city, state, and ZIP code.
  10. Previous Address: List your previous address if you have moved within the past two years.
  11. Accompanying Minors: If you are bringing minors, list their names, dates of birth, and their relationship to the inmate.
  12. Previous Visits: Indicate if you have visited another inmate in a California prison and provide details if applicable.
  13. Criminal History: Answer whether you have ever been detained, arrested, or convicted of a crime, and provide details if necessary.
  14. Probation/Parole Status: Indicate if you are currently on probation, parole, or any other court-imposed program.
  15. Discharge Approval: If you were recently discharged from an institution, ensure you have prior written approval from the Warden to visit.
  16. Minor Consent: If you are under 18 and not an emancipated minor or the inmate's legal spouse, obtain notarized consent from a parent or legal guardian.
  17. Disability Accommodations: If applicable, provide a statement from your physician regarding any special requirements related to your disability.
  18. Signature: Sign and date the form, confirming that you understand and agree to follow all relevant rules and regulations.

After completing the form, review it to ensure all sections are filled out accurately. Once confirmed, mail it directly to the visiting office of the institution where the inmate is confined. You will receive notification regarding your application status, whether it is approved or disapproved.

Frequently Asked Questions

  1. What is the purpose of the Visiting Questionnaire form?

    The Visiting Questionnaire form is used by the California Department of Corrections (CDC) to assess whether a visitor is eligible to visit an inmate. The information provided helps officials determine if your application will be approved or denied. It's crucial to fill out the form accurately, as any omissions or false information may result in denial of visiting privileges.

  2. Do I have to provide my Social Security number?

    Providing your Social Security number is optional. According to the Privacy Act of 1974, you can choose not to include it. However, keep in mind that omitting or falsifying any information on the form could lead to denial of your visiting application.

  3. What should I do if I have a disability?

    If you have special requirements due to a disability, such as needing mobility assistance or medical devices, you must attach a verifying statement from your physician. The CDC aims to accommodate visitors with disabilities while ensuring the safety and security of the institution. If you have any questions, reach out to the institution where the inmate is located.

  4. How will I know if my application is approved or disapproved?

    If your application is approved, the inmate will be notified, and it is their responsibility to inform you. If your application is disapproved, the institution will send you a notification by mail. You will not be allowed to visit until your application receives approval.

Common mistakes

Filling out the Visiting Questionnaire form can be a straightforward process, but there are common mistakes that can lead to delays or denials. One major error occurs when individuals fail to provide complete information. Each section of the form is crucial for the approval process. Omitting details like the inmate’s CDC number or your own identification can raise red flags and potentially result in a denial. Always double-check that all fields are filled out completely before submitting.

Another frequent mistake is using incorrect or inconsistent names. It’s essential to print your name exactly as it appears on your photo identification. If you have ever used another name, it’s important to list that as well. Inconsistencies can lead to confusion and may cause your application to be rejected. Make sure to include any maiden names or aliases to avoid complications.

People often overlook the importance of providing accurate dates. This includes your date of birth and the dates related to any previous visits or legal issues. Incorrect dates can lead to misunderstandings or indicate a lack of attention to detail, which may affect your chances of approval. Always verify that the dates you provide are correct and formatted properly.

Lastly, many applicants neglect to read the instructions carefully. The form includes specific requirements, such as the need for notarized consent for minors or verification of any disabilities. Ignoring these details can lead to unnecessary delays. Take the time to read through the entire form and ensure that you understand what is required. Being thorough can save you time and stress in the long run.

Documents used along the form

The Visiting Questionnaire form is an essential document for anyone wishing to visit an inmate in a California correctional facility. Alongside this form, several other documents may be required to ensure a smooth visiting process. Here are four commonly used forms and documents that accompany the Visiting Questionnaire.

  • Photo Identification: Visitors must present a valid form of photo ID, such as a driver's license or passport. This identification verifies the visitor's identity and ensures that they match the information provided in the Visiting Questionnaire.
  • Minor Consent Form: If the visitor is under 18 years old and not an emancipated minor, a notarized consent form from a parent or legal guardian is necessary. This form ensures that minors have permission to visit an inmate and outlines any specific requirements for their visit.
  • Discharge Paperwork: If the visitor has been recently released from a correctional facility, they may need to provide documentation of their discharge. This paperwork confirms that they have completed their sentence and are eligible to visit an inmate.
  • Medical Verification Statement: For visitors with disabilities, a statement from a physician may be required. This document outlines any special accommodations needed during the visit, ensuring that the facility can provide appropriate support.

Being prepared with these documents can help facilitate the visiting process and avoid any potential delays. Always check with the specific institution for any additional requirements or changes to the visiting policy.

Similar forms

The Visiting Questionnaire form shares similarities with several other documents used in various contexts. Each of these documents serves a specific purpose in gathering personal information, verifying identity, or assessing eligibility for participation in specific activities. Below is a list of nine documents that are similar to the Visiting Questionnaire form:

  • Visitor Application Form: This document collects personal details from individuals wishing to visit a facility, ensuring they meet specific criteria for entry.
  • Background Check Authorization Form: Used to request permission to conduct a background check on an individual, this form typically requires personal information and consent for verification.
  • Inmate Visitor Registration Form: This form is designed for individuals who want to register as visitors to an inmate, collecting information about the visitor and their relationship to the inmate.
  • Employment Application: Similar in structure, this document gathers personal and professional information to evaluate a candidate's suitability for a job position.
  • School Registration Form: This form collects personal information about students and their guardians to enroll them in an educational institution, similar to how the Visiting Questionnaire gathers information for inmate visitation.
  • Medical History Form: Patients fill out this form to provide healthcare providers with essential information about their medical background, akin to how visitors disclose their history for approval.
  • Event Registration Form: Used for signing up participants for events, this document collects personal details and sometimes requires background information for security purposes.
  • Consent for Treatment Form: This form requires individuals to provide personal information and consent for medical treatment, similar to the consent needed for visitation in correctional facilities.
  • Parole Application Form: Individuals seeking parole must complete this form, providing detailed personal information and history, paralleling the requirements of the Visiting Questionnaire.

Dos and Don'ts

When filling out the Visiting Questionnaire form for the California Department of Corrections, there are several important guidelines to keep in mind. Following these guidelines can help ensure a smoother application process. Here are eight things to do and not do:

  • Do print or type your answers clearly to avoid confusion.
  • Do provide accurate information about your identity and relationship to the inmate.
  • Do include your Social Security number if you feel comfortable doing so, but remember it is optional.
  • Do ensure that you sign and date the form before submitting it.
  • Don't omit any requested information, as this may lead to denial of your visiting privileges.
  • Don't provide false information or misrepresent your identity, as this is a serious offense.
  • Don't forget to attach any necessary documents, such as proof of disability accommodations or notarized consent for minors.
  • Don't submit the form without checking it for completeness and accuracy.

By adhering to these guidelines, applicants can help facilitate a more efficient review process and increase the likelihood of approval for visitation.

Misconceptions

  • Misconception 1: The Visiting Questionnaire is optional for all visitors.

    Many people believe that filling out the Visiting Questionnaire is merely a suggestion. In reality, it is a required form that must be completed to determine eligibility for visiting an inmate. Without this form, you will not be allowed to visit.

  • Misconception 2: Providing a Social Security number is mandatory.

    Some individuals think that they must provide their Social Security number on the form. However, according to the Privacy Act of 1974, it is optional. Omitting this information will not automatically disqualify your application, but it is important to provide accurate information to avoid potential issues.

  • Misconception 3: If the form is submitted, a visit is guaranteed.

    It's a common belief that submitting the Visiting Questionnaire guarantees a visit with the inmate. This is not true. The institution will review the questionnaire, and approval is based on various factors, including the applicant's background and any potential security concerns.

  • Misconception 4: Minors can visit without any special requirements.

    Some may assume that minors can visit inmates freely. In fact, if a visitor is under 18 and not emancipated or the inmate’s legal spouse, they must have notarized consent from a parent or guardian. Additionally, a responsible adult must accompany them, ensuring that all legal requirements are met for the visit to occur.

Key takeaways

Filling out the Visiting Questionnaire form for the California Department of Corrections is a crucial step in the process of visiting an inmate. Here are some key takeaways to ensure you complete it accurately and understand its importance:

  • Complete Information: Provide all requested details accurately. Missing or incorrect information can lead to denial of your visiting request.
  • Optional Social Security Number: While you can provide your Social Security number, it is not mandatory. However, omitting it does not exempt you from providing complete and truthful information.
  • Mail Directly: Send the completed form directly to the visiting office of the institution where the inmate is housed. Do not send it to any other location.
  • Relationship Disclosure: Clearly state your relationship to the inmate. This helps officials understand the context of your visit.
  • Criminal History: Be honest about any past detentions, arrests, or convictions. Failure to disclose this information can result in disapproval.
  • Minors Require Consent: If you are under 18, you must have notarized consent from a parent or legal guardian to visit, along with an approved adult escort.
  • Disability Accommodations: If you have a disability, attach a statement from your physician to ensure necessary accommodations are provided during your visit.
  • Understand the Rules: Familiarize yourself with the visitation rules, including search policies and what items are prohibited on institutional grounds.
  • Notification of Approval: If your application is approved, the inmate will be notified. If disapproved, you will receive a notification by mail outlining the reasons.

By following these guidelines, you can help ensure a smoother process for your visit to the inmate. Always remember that accurate and honest information is key to gaining approval.