FILE #:
Hampton Roads Regionauail
!ij- --i' i ,;.' PRE.EMPLOYMENT POLYGRAPH , iat , ,lì DßMINATION QUESTIONNAIRE
Position Applied
Date of Exam:- Time in:_ Time our_
Name of Applicanü
ssN
Previous Exarn:
CONCLUSION: NDI NC
Examiner's lìnmma¡f¡
ÐßMINER'S SIGNATURE:
Hampton Roads Regional Jaíl Prge I P oly graph Examin ation B o o kI et INSTRUCTIONS TO APPLICANT
I Each applicant is hereby advised that the contents of this booklet are held strictly CONFIDENTIALand no information is disseminated to any person exceptwhen essential to the conduct of oflicial Reeiona[ail business; zuRTHER, THAT THE INTENTIONAL OMISSION OR FAISIFICATION OF ANIY MATERIAL FACT ISJUST CAUSE FOR DISQUALIFICATION OR DISMISSAL OF APPUCANT ON GROUNDS OF DISHONESTY. Every answer herein enûered will be checked during the polygraph examination.
2 If you desire to make a lengthy explanation in your reply, Írnswer the question btiefly as best you can, then put a circle around the question number. The examiner will give you an opporhrnity to make any desired explanation regarding any question so marked. Please sþ this page (insfuctions to applicant) below to indicate your understanding of instuctions.
3. The Americans with Disabilities Act prevents the examiner from asking questions regarding your health and any disability during a pre€mployment examination. A polygraph examination is stessfi¡l. If you have heartproblems, hypertension or any other ailmentwhere stress may be denimenøl to your health, it is strongly sugest you contact a health care professional for advice prior to tåking this examination.
4. Now read the next four pages. The first segment is the STANDARDS OF PRACTICE. It is the wrinen explanation of the regulations governingpolygraph examinations established by the Departnent of hofessional and Occupational Regulation. Please sþ and date each page. The second segment is a STATEMENT OF RELEASE, yoü wrinen permission for the examiner to adminisûer your tesl Please print your name and age at the top of the STATEMEI{T OF RELEASE, then sþ and dare the bottom of each page.
Applicands Sigrahre Date-
Hampton Roads Regional Jail Pege 2 Polygraph Examination Booklet STANDARDS OF PRA TICE PRE.EMPLOYMENT POLYGRAPH DßMINATÏON
Before beginning this polygraph examination, I am required, pursuant to the Standards of Practice established by the Departnent of Professional and Occupational Regulation, to explain i" ttriting provisions 3.1 through 3.8, of the regulations governing polygraph. This form is that-sninen explanation
Upon your uriüen reques! an audio-tape record of this examination will be made. The recordingwill be kept with other records required by the Departnent of Professionál and Occupational Regulation and upon request a copy will be made available ûo the Deparünent of Professional and Occupational Regulation, to you or your afiorney. A fee of $25.00 will be charged to you for furnishing a copy of this tape recording. (3.2)
You may request a copy of all portions of any report pertaining to this examination which was prepared by the examiner and provided to any pen¡on. In the event you wish a copy of such report, you must make your request in vyriting:ûo me. The report will be provided to you within l0 business days of your request, or of the date the report is provided to any person, whichever may occur larcr. A fee of $1.00 per page will be charged to you br your copy. (3.3)
Ð(CEITIIONS: This q'rinen explanation is not required when the examination is being conducûed by, or on behalf oi the Commonwealth or local govemment for the purpose of preventing or detecting crime or enfiorcerhent of penal laws. Under these conditions, you are not entitled to have the examination recorded, and you are not entitled to a copy of any wriuen report prepared. However, a verbal erplanation of the following provisions is required. (3.4) kior to administering the polygraph tesÇ you will be infiormed of all issues ûo be covered, and all iæms being reported by the examiner to any other person. (3.5)
Your wrinen permission is required afær fulfiltins the requirements of section 3.1. (3.6)
Applicant's
Exarniner's
Hampton Roaù Regional Jail Prge 3 P o ly grap h Examination B o oflet STANDARDS OF PRACTICB (Continued):
You have certain rights rurder the Standa¡ds of Practice; itis required thatthese standards be explained ùo you and thatyou understand each of these standards.
The standards are:
l. AII questions asked during the test will be in wrinen form and will be read to you.
2. Either you or the examiner may end the examination at any trme.
3. This examination is exempt from 540.1-51.4:3 of the Code of Virginia (1950 as amended), therefore questions concerning sexual crimes may be asked.
4. No questions concerningyour laufi¡I, religious, political affliations or labor activities will be asked, unless such aftiliations are inconsistent with the oath for public law enforcement ofñcer.
5. My full name is . I am licensed by the Departrnent of hofessional and Occupafional Regulation located at 3600 West Broad Street, Richmond, Virginia zïz}O,Telephone #l-804-367-8500. (3.7)
I have carefully read the above Sta¡rdards of hactice and I fully understand all of is contents. The examiner has answered all questions asked by me concemingthe examination. In acknowledgement thereof,I affixmy sþature hereunder
Applicant's
Examiner's
Hampton Roads Regíonøl Jail Pege 4 P o lygrap h Examínatíon B o o Het Hampton Roads Regional Jail PRF-EMPLOYMENT POLYGRAPH Ð(AMINATION STATEMENT OF RELEASE
I, age free will a¡rd without duress, agree, in connection with a pre-employment inquiry, to submit to a polygraph examination.
I further authorize the use of the required polygraph instrument attachments to my person in order that the necessary recordings can be made. I also agree that the results and opinions of such tests can be made knorryn ONLY TO THE OFFICE OFTHE REGIONALJAIL-1æars,ofmyown and any authorized review uResults' ag€ncy. does not include admissions and confessions made prior to or after the polygraph tests.
I hereby waive and release any and all claims and causes of action of every kind against the Hampton Roads RegionalJail, its officers, employees, and polygraph examiner, in cormection with taking of such polygraph tests, or in connection with any investþation concerning my bacþround, which I may or in the fuûrre, have arising out of or in connection with the aforesaid polygraph examination.
I understand that ttris polygraph examination will be adminisæred by a trained, professional polygraph examiner who is licensed in this State and who is a graduate of a recognized polygraph training institute.
I understand that I will be informed of all the issues ûo be covered during the polygraph æst and of all the items to be reported to any other person and that all the issues and questions to be asked durins the polygraph examination will be discussed with me, reduced ø urriting a¡r read üo me before I take said polygraph examination
No questions shall be asked concerning any examinee's lawfìrl religious affiliations,lar¡Á¡l political afliliations, or lawfirl labor activities. This provision shall not apply to any such afüliation which is inconsistent with the oath of oflice for public law enforcement oflicers.
Applicant's
Examiner's
Hampton Roads Regional Jail Page 5 Polygraph Examination Booklet STATEMENT OF RELEASE (Continued):
I understand thatif awritten reportis to be prepared by the examiner and provided ûo any person, the examinee shall be entitled to a copy of ttrat n'rinen report pertaining to this or her examination. The examinee shall exercise this entitlement by making writren request to the Personnel section of the Hampton Roads Regionauail. Such reportwill be provided to the examinee within ten (10) business days of the time the wrinen report is provided to the Personnel section of the Hampton Roads RegionalJail or receiving the examinee's wriüen request, whichever occurs later. A charge of one dollar per page is required for any copy provided: (Virginia Code 54-gl7).
I understand that I may request that the polygraph examination be tape re-corded and that I ca¡r receive a copy of the tape recording for a fee of $25. (Virgnia Code 54-9171
I understand that I have the right to terminate this examination at any time I so desire.
I understand that the polygraph examination is an interview process which includes the use of a polygraph insüumenL I fuither understand that the examination consists of both a pre-test and post- test phase, as well as the ach¡al instrument testing phase.
The American Disabilities Act prevents the examiner from a,sking questions regarding your health and any disability during a pre-employment e;camination. A polygraph examination is stessful. If you have health problems., hlpertension or any other ailment where stess may be deuimental to your health, it is strongly sugested that you contact a health care professional for advice prior to taking this examination.
I have received a copy of the Standards of Practice, examiner's name and the gS., address, and ælephone number of the Departrnent of Professional and Occtrpational Regulation.
I have carefully read all of the foregoing and fully undersand all of its contents. [n acknowledgement thereof I afïix my sþature hereunder
Applicant's
Examiner's
Hampton Roads Regionøl Jaíl Pege 6 Polygraph Examinatíon Booklet NAME AND ADDRESS
l. List current legal name and address: ...
2. Date of Birth:
3. Have you ever gone by a different nameP Explain:
4. Has your name ever been changsd by court action?
5. Have you ever used and aliasP E Yes tr No F.xplain:
MARITAL STATUS
l. Single tr Manied tr Divorced El Widowed El Separated tr
How long have your been marriedP
2. Do you have any children? List: nalne, sex, age:
PERMANENCY INTENTIONS
l. Whatother law enforcementagencies do you have applications with?
2. Have you ever been employed by another law enforcement agpncy? YesE NoE
3. \ühy did you leave that deparrnent(s) ?
'Were 4. you ever rejecùed by another law enforcement agencyP E Yes El No
5. If you are presently or previousþ employed by another law enforcement agency, did you ever receive disciplinary actionP E Yes E No Explain:
Hampton Roads Regional Jaíl PrgeT Polygraph Exømination B ooWa EMPLOYMENT
l. Present employer/how long employedP
2. Present job responsibilities ?
3. Military service - include: branch, entrance and discharge date, type of discharge? -
'Were 4. you ever fired or dismissed from ajob? E Yes tr No Fxplain:
5. Did you ever quit ajob before you were about üo be firedP tl Yes tl No Explain:
6. Were you ever reprimanded by any supervisor for berrg late or absent? E Yes tr No Explain:
7 Were you ever reprimanded for misconduct or not doingyour job properly ? EYes trNo Explain:
Hanpton Roads Regíonal Jail Prgc 8 Poly gpaph Examinatìo n B o oH et ACCTDIÐ.NT ANp TRATFIC VrQI#ULON RECORp l. Do you have a valid license? E Yes EI No
Class of license
State
License #
2. Does your license contain any restrictionsP E Yes El No
3. How long have you been a licensed driver?
4, List all accidents you have had as the operator of a vehicle; include dates, if investþted by police, and if ticketwas issued:
'Were 5. you ever involved in a hit and run accidentP E Yes tr No Explain:
6. Do you have any pendinglawzuits because of an accidentP El Yes tr No Explain:
7. Have you ever possessed a driver's license from any other stateP El Yes E No List state(s):
8. Has your driuing license ever been suspended or revoked in this state or any other stateP E Yes tr No Explain:
'Were I you ever denied auto insuranceP El Yes tl No Explain:
10. List all tafüc tickets (exceptparkingyou have received in this state or any other state...include dates, where received and disposition:
I l. Do you have any parking tickets, in this stat€ or any other stare, that have not been paidP E Yes tl No
Hampton Roads Regional Jail Pege 9 Polygrøph Examination BooWet ARRESTS AND/OR UNDETECTED CRIMES
1. Have you ever committed or participated in or conspired to commit any of the following serious crimes:
Murder tr [.arceny
Rape E Arson EI
Robbery tl Mayhem
Manslaughter Cl Burslary tr
Sodomy tr Sex Crimes t
Explain:
2. Have you ever been arrested as an adultP E Yes tr No Explain:
3. Do you have any criminal charges that have been dismissed? E Yes tr No Explain:
4. Have you ever been served a sunrmons to appear in courtP E Yes tr No Explain:
5. Have you ever been in a jail, prison, training school because of a motor vehicle charge or criminal charge? El Yes tr No Explain:
6. While in the service did you receive any tlpe of punishmen(s) ... include fines, extended duty days, extended duty hours, loss of leave, loss of rank; name type of hearing: E Yes E No Explain:
7. Did you ever serve time in a military stockade? E Yes E No
8. Were you honorably discharged from the sewice: E Yes tl No
Hampton Roads Regional Jail Page 10 P o ly graph Emmin ation B o o Het ARRESTS AND/OR UNDETECTED CRIMES (Continued)
9. Did you complete your entire enlistnentperiod? E Yes tr No Explain:
10. Did you ever steal anything of valueP E Yes tr No Explain:
I I Did you ever steal an¡hing valued at under 250.00P E Yes E No
Include:
Shopliftins tr From other persons tr
Money From employers
Merchandise From aresidence
OfIice Supplies From parents /relatives EI
Government u Receive sûolen goods tr
Other:
12. Have you ever commiüed a crime for which you were notcaught El Yes tr No Explain:
GAT{BLING
I Have you ever participal€d itt any illicit form of ga¡nblingP EYes trNo Explain:
2 Do you have any gambling debts at presentP E Yes trNo How much?
Hampton Roads Regional Jail Pege 11 Polygraph hamination B ooilet ILLEGAL SUBSTAN.CES l. Are you currentlyusinganyi[egal drugs or otherüegal substances? E Yes tr No
2. Have you ever sold or possessed any illegal drugs or narcoticsP EYes trNo
Indicate YES or NO to each of the followingquestionsP
YES NO tr E 1. Have you ever used arr alias or incorrectname to commitfraud? tr tr 2. Have you told me aboutall the tafüc tickets and accidents you have had while operatingavehicle ?
EI 3. Do you garnble more than whatyou told me aboutP
4. Have you ever been fired from anyjob you ever hadP tr 5. Are you holdins back information about ever being a¡rested or being in jailP tr 6. Have you ever commited or taken part in any of the serious crimes I've asked you aboutP tr u 7. Did you ever steal anythingvalued over $50.00 P tr tr 8. While a law enforcement ofñcer have ever used your authority to commitan illegal act?
9. Did you deliberaæly lie to any of the questions in this bookletP
Hampton Roads Regíonol Jail Prge 12 P oly graph Examinatíon B o o H et I Did you ever directly or indirectly solicit a bribe or gratuity P E Yes E No F,rylain:
2. Did you ever lose your t€mperwith a subject P EYes trNo
3 Have you ever used excessive force on a subject? EYes trNo
4. Have you ever had any brutality complaints P El Yes E No
5 Did you ever keep anything of value from a subject or civilian P E Yes tl No
6. Did you ever keep lost or found property received from a citizen P El Yes El No
7 Did you ever take property from a place where you were invesfuating or guarding P El Yes tr No
Hampton Roads Regional Jaíl Pege l3 Polygraph Emminøtion Bo oldet