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At Silicon Valley Toxics Coalition and the Prison Activist Resource Center we have been working to end the exposure to toxics of people working in electronic recycling programs in prison, particularly in UNICOR work programs within the Federal Prison System. Sworn statements from people in prison have played a vital role in advancing our understanding of how electronic waste is recycled in prison. We suggest that after returning this form, you file any complaints you may have within your prison?s internal administrative remedy process, in order to preserve your ability to sue. Please take a moment to fill out this survey and return it to our legal support: Michael Couzens, Attorney at Law, P.O. Box 3642, Oakland, California 94609.

1. Do you wish to keep your identity anonymous?

2. Are you currently working in a work program in electronics?

3. Work: Recycling, Manufacturing, Repair or other: Where: Federal, State, County or Other Prison.

4. If you are working in a Federal Prison, are you working for UNICOR?

5. What is the name of the facility you are in?

6. How long have you worked in this program? from (mo./yr.) to (mo.yr.)

7. Do you have any health concerns that you believe are related to your work? If so, what have you done to get redress?

8. What, if any, special care is taken to protect your health and safety when handling electronics? Are there any special steps you believe should be taken, but are not?

9. Has there ever been environmental/toxic materials testing at your site?

If so, have you ever witnessed manipulation of activity or change in routine specifically because of the tests? [Example: stopping work before or sudden clean-ups to pass air quality tests] How many times? When were the tests (mo./yr.)? Do you know what they were testing for? Please list.

10. Have you had a blood sample taken and tested since you began working with electronics in the program?

If so, do you know what they were testing for? Please list. Were the results shared with you?

How often have you been tested?

11. When doing this work, what do you wear? Are you provided with personal protective equipment? What?

12. Have you ever experienced personally or seen intimidation, discipline or firing of workers as a result of attempts to obtain information about or address problems in the work environment?

13. Have you seen or been involved in accidents, injuries, breakage of equipment at the worksite? If so, how often, and of what nature? Please describe.

14. What tools are you given to work with? Would you describe the equipment provided to do your job as adequate or inadequate? Please explain.

15. Have you ever seen prison guards questioned, disciplined or fired for workplace corruption or violating rules (i.e., refusing to provide safety equipment, setting electronics aside for personal profit)? Explain.

16. If you are working in recycling, do you know where the electronic equipment comes from? Please detail (i.e. names of school districts, universities, agencies, hospitals, corporations, etc., that ship electronics)

17. Can we use your statements here in reports or media work on these issues? (anonymous or with name?)

18. What is your race/culture/ethnic background?

19. Do you want to maintain communication with us regarding this work and any future actions we may take?

20. Please provide contact information for a friend or family member outside of prison. I swear under the penalty of perjury under the laws of the United States of America that the foregoing statement is true and correct. Sign and print your name, with your prisoner ID# and date signed.

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