Page 18 of The Dream Hotel

Safe-X Security Questionnaire

(Basic-10)

If you check the Yes box on a question below, you must provide details on the pop-up screen.

Yes

1. Are you aware of any retainee who plans to harm someone at this facility?

2. Are you aware of any retainee who plans to harm someone outside this facility?

3. Are you aware of any retainee who plans to harm themselves at this facility?

4. Are you aware of any retainee (or retainees) planning to escape, riot, or encourage others to escape or riot?

5. Are you aware of any retainee (or retainees) planning to set fire or otherwise damage this facility?

6. Are you aware of any retainee who is using narcotics, alcohol, or any other controlled substance while at this facility?

7. Are you aware of any retainee who is in possession of contraband, including phones, smart devices, cigarettes, vape pens, lighters, or matches?

8. Are you aware of any retainee who is in possession of weapons, including guns, knives, blades, or sharp instruments?

9. Are you aware of any retainee who is in possession of prohibited documents or reading material?

10. Are you aware of any improper conduct by an attendant at this facility?

? I acknowledge that my answers are voluntary and have not been coerced by staff or visitors.

? I understand that answers to this questionnaire may lengthen or shorten the retention period of any named individual, including myself.

Name: _____-_____-_____-_____-_____-__

Signature: _____-_____-_____-_____-____