"DHS-approved format for letter restricting access - DOC"
DHS approved format for letter restricting access [Date] Certified and regular mail [required by OAR] [Name and address] This letter provides notice that the Department of Human Services is placing restrictions on your access to the Human Services’ premises at [Location] and its occupants. This restriction is effective immediately. If you enter the above described DHS property, law enforcement will be contacted and you may be subject to arrest for criminal trespass in the second degree pursuant to ORS 164.425. The restriction extends to the building, the parking lot and grounds. [If this is a Multiple-tenant building, add common areas such as hallways, cafeteria—be specific and coordinate with other occupants.] The restriction shall continue until the Department determines that you no longer pose a threat to DHS employees and premises. At that time a notice will be sent to you that the restriction has been removed. Restrictions are placed on your access to the premises and its occupants, including phone contact, as the result of the following conduct that is prohibited by Oregon Administrative Rule 407-012-0010. 1. 2. [Be very specific here about what was said or done, where and on what date and time. List all incidents of prohibited conduct in accordance with OAR 407-012-0010 that occurred. For example: 1. At 3:00 pm on December 7, 2007 you told your caseworker that she would get what was coming to her and that you knew where she lives and where her children go to school. 2. At 11:00 am on December 12, 2007 in the lobby of the above building you grabbed another client.] The Department will provide you with services for which you are eligible. However, your business with this office will be conducted only by [mail, phone, etc]. If a face-to-face meeting is needed, you will need to schedule an appointment before coming in to the office. You must limit your phone contact to the following individual. Name: Title: [This person must be a manager] Phone #: Process for requesting review of this decision If you do not agree with this restriction, you may request a review. Your request must be in writing and must indicate what about this determination is in error. If you believe that your conduct resulted from a disability, you must notify DHS of your disability. DHS will explore the possibility of a reasonable accommodation in accordance with OAR 407-012-0010(3). DHS 0008I (Instructions for DHS 0008 (04/08) Requests for review must be received by [put date: 15 business at the following days] address or faxed to 503-378-2899. ATTN: Review Committee DHS Administrative Services Division 500 Summer Street NE, E94 Salem OR 97301 Pursuant to OAR 407-012-0025, the determination may be reviewed on or after [6 mos—put date]. You should follow the same process indicated above. cc: [Name of Law Enforcement Agency (required by OAR 407-0012-0020(g)] DHS 0008I (Instructions for DHS 0008 (04/08)