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CHP – Pre-Investigation Questionnaire

CHP – Pre-Investigation Questionnaire

 

Pre-Investigation Questionnaire (v2)

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Candidate Details

Candidate Name*

Terms

As an applicant for a position with a Public Safety Agency, I am required to complete this Pre-Investigation Questionnaire. I am admonished that any false statement or omission on this questionnaire may cause my name to be removed from the eligibility list or be considered for immediate dismissal if an appointment is made.
Do you understand this statement?*
Do you have any questions about this admonishment?*
Clear Signature
MM slash DD slash YYYY
Read and answer the following questions carefully and honestly. A “Yes” answer may not, in and of itself, be grounds for disqualification or non-selection, whereas an untruthful response could be. Answers may also be subject to verification by a polygraph examination and / or medical examination, including but not limited to, a drug screening. ALL questions answered “Yes” require an explanation. All questions must be answered completely, accurately, and truthfully. If the incident has occurred more than once, make sure you explain all occurrences.

The questions are used to help assess your personality traits, past behavior, integrity, interpersonal skills, decision-making abilities, and overall suitability for the position. For this reason, in addition to being evaluated on your moral character and suitability, you will also be evaluated on your ability to complete this questionnaire accurately. Part of the assessment is your ability to follow instructions properly.

PERSONAL

Are you known by, or have you used, any other name, moniker or aliases?*
Are you concerned that you may not meet one or more of the minimum qualifications?*
Have you any concerns about an investigation into your background?*
Have you ever been reported as a runaway or missing person?*
Have you ever been detained by a law enforcement agency for any reason??*
Are you afraid of physical combat?*
Have you ever legally changed your name?*
Have you ever used any other social security number?*
Do you use another mailing address? (Residential, Commercial, P.O. Box)?*
Did you tell any of your personal references, coworkers, or supervisors what to say, or what to NOT say, if contacted by background investigators?*
Have you ever viewed any websites or read any materials that describe how to beat or fool a polygraph or voice stress examination?*
Have you ever engaged in civil disobedience?*
Have you ever been listed in a police report as a victim, witness, lead, or suspect?*
Did you threaten any of your co-workers, supervisors, references, neighbors, or roommates/housemates, past or present, regarding potentially harmful information they might reveal?*
Do you claim dual citizenship, or nationality, with the United States and any other country?*
Have you ever attempted suicide or intentionally harmed yourself?*
Have you ever participated in a protest or demonstration of any kind?*
Have you ever told a serious lie to someone in authority?*
Has the fact that you want this job caused any conflict with your family or friends?*
Do you currently use more than one email address?*
Have you ever visited an inmate in a jail, prison, or other custodial facility?*

SOCIAL MEDIA / INTERNET

Do you have, or have you ever been a member of a computer social networking or social media site including Facebook, Twitter(X), LinkedIn, Instagram, TicTok, Reddit, Pinterest or any other social site?*
Common platforms include (but are not limited to): Facebook. Instagram, LinkedIn, TikTok, Reddit, Twitter(X), and Pinterest.*
Platform Name
Is the account active?
Link to Public Profile
Public Profile Name
 
Have you ever viewed or posted on an online message board or online forum?*
Common platforms include (but are not limited to): Facebook. Instagram, LinkedIn, TikTok, Reddit, Twitter(X), and Pinterest.*
Platform Name
Is the account active?
Link to Public Profile
Public Profile Name
 
Do you have any social networking accounts under a different name or identity?*
Common platforms include (but are not limited to): Facebook. Instagram, LinkedIn, TikTok, Reddit, Twitter(X), and Pinterest.*
Platform Name
Is the account active?
Link to Public Profile
Public Profile Name
 
Have you currently have or ever had a blog or participated in blogging website(s)?*
Common platforms include (but are not limited to): Facebook. Instagram, LinkedIn, TikTok, Reddit, Twitter(X), and Pinterest.*
Platform Name
Is the account active?
Link to Public Profile
Public Profile Name
 
Have you ever used a cyber aliases, nicknames, or monikers on social media or the internet?*
Enter all cyber aliases, nicknames, or monikers you have ever used on social media or the internet*
Aliases / Nickname
Platform used on
Is the account active?
Link to Public Profile
Public Profile Name
 
Have you ever posted a video on YouTube or another video site?*
Common platforms include (but are not limited to): Facebook. Instagram, LinkedIn, TikTok, Reddit*
Platform Name
Is the account active?
Link to Public Profile
Public Profile Name
 
Will a search of the internet find any content that you are associated with that may be concerning?*
Common platforms include (but are not limited to): Facebook. Instagram, LinkedIn, TikTok, Reddit, Twitter(X), and Pinterest.*
Platform Name
Link to Public Content
 
Have you ever accessed someone else's password-protected account without consent or knowledge, including e-mail, Facebook, MySpace, Twitter, iTunes, Linkedin, etc?*
In the last 5 years, have you deleted or deactivated any of your social media accounts?*
In the last 5 years, have you deleted any posts or photos on any of your social media accounts because you thought they might reflect poorly upon you during the background process?*
Did you change the status of any of your social media accounts to be restricted in any way because you thought they might reflect poorly upon you during the background process?*
Have you ever used social media or the Internet to obtain information for the purposes of committing a crime or illegal act?*
Have you ever used the Internet or Social Media to taunt, harass, intimidate, or otherwise annoy another person?*
Will any of your references, employers or anyone else tell us about any areas of concerns with your use of social media or the internet?*

RELATIVES & REFERENCES

Might someone tell us you have a personality characteristic that is unsuitable for public safety employment (i.e., violent temper, violent tendencies or suicidal tendencies)?*
Might someone tell us you are not always honest or that you tend to be less than truthful?*
Might someone tell us you do not always treat some people fairly or impartially?*
Might someone tell us you lack the interpersonal skills to work in Public Safety?*
Might someone tell us you are unable to physically handle the position?*
Might someone tell us you tend to manipulate people to get what you want?*
Might someone tell us that you have a prejudice or bias toward minority groups or certain types of people?*
Might someone tell us that you tend to be discourteous, impolite, disrespectful, or rude to people?*
Might a current or past supervisor not recommend you for a position of public trust?*
Might a relative, or other reference, give you an unfavorable recommendation?*
Might a former spouse or significant other give you an unfavorable recommendation?*
Have you lived or do you live, with friends or family members that have served time in any prison or jail facility?*
Might someone tell us that you tend to be offensive, vulgar, bad mannered, or uncouth to others?*
Did you ask or tell any of your personal references to lie or omit information about your personal life?*
Have you had a past romantic relationship (either serious or casual) since the age of 16?*
List all of your current and past romantic relationships, both serious and casual, that you have had since the age of 16. Do not include your current spouse or former spouses.*
First Name
Last Name
Email Address
Phone Number
Date of Relationship (From-to)
 

EDUCATION

Have you ever cheated on any college examination or test?*
Have you ever cheated on any high school examination or test?*
Have you ever cheated on a performance examination, including a physical abilities test?*
Have you ever altered, falsified, counterfeited, or forged any school record, application, or school transcript?*
Will any teacher or other school official tell us you had behavioral problems while attending any school?*
Have you ever taken a concealed firearm or weapon to any public/private school or on any college campus?*
Have you ever threatened any teacher, school official or other staff member with violence?*
Have you ever hit, struck, pushed, or injured any teacher, school official or staff member?*
Have you ever been suspended or expelled from any private or public school or college?*
Have you ever called in a bomb threat to any school or college?*
Have you ever been involved in any physical fights in high school or college?*
Have you ever failed or dropped out of any law enforcement academy or training class?*
Have you ever had any contact with campus police?*
Have you ever been academically dismissed?*
Have you been investigated in school for plagiarism or cheating?*
Have you ever been placed on academic or athletic probation?*

RESIDENCE

Do you have any problems getting along with any of your current or past neighbors?*
Have you any reason to be concerned about an investigation into the places you have lived?*
Are you currently living with a convicted felon or with someone who is on parole from prison?*
Are you currently living with someone who is committing crimes?*
Are you currently living with someone who is a registered sex offender?*
Are you currently living with someone with violent tendencies?*
Are you currently living with someone who has committed a hate crime?*
Have you ever been threatened with eviction or been evicted?*
Has anyone complained to police about any activity or commotion at your home?*
Have you ever allowed someone to keep, store or hide stolen property at your home, garage or property?*
Have you ever been asked to leave a residence because of your temper or argumentative behavior?*
Have you ever allowed someone running from the police or other authorities to stay at your residence including juvenile runaways and wanted persons?*
Have the police or a law enforcement officer visited your home for the purpose of investigating a crime or to ask you or any member of your household questions about a crime?*
Has anyone in your household ever been arrested?*

RESIDENCE (continued)

Have the police been to your home to investigate a disturbance or loud argument?*
Have you ever forced a family member out of your home?*
Have you ever had a party at your residence where the neighbors complained about the noise?*
Have you had a party at your residence where illegal drugs were being used?*
Do you own any other properties other than your primary residence?*
Have you ever been late paying rent or failed to pay rent at any current or former residences?*
Have you ever moved to avoid paying rent?*
Have you ever left any residence under unfavorable circumstances?*
Have you ever been evicted, threatened with eviction, or served a 3-day notice to “Pay or Quit”?*
Have you lived at a residence that has gone through foreclosure proceedings?*
Have you ever damaged or removed household items from a foreclosure residence you were vacating?*
Have you ever lived at a property where you were not listed on the lease as required?*
Are you currently or have you ever lived with a person who was, or is, wanted for questioning by law enforcement about any crime?*
Have you ever left a residence owing utilities, rent, or other household expenses?*

EXPERIENCE & EMPLOYMENT

Have you reason to be concerned about an investigation into your work history?*
Is anyone likely to report derogatory information about your work history or work performance?*
Would any past employer decline to rehire you because of your behavior, conduct, or attitude?*
Have you ever committed a dishonest, immoral act to obtain a job, promotion, transfer, or higher performance rating?*
Have you ever done anything improper, that if caught, you would be fired or suspended?*
Have you ever been found to be in violation of any law, regulation or work policy involving discrimination, sexual harassment, or workplace violence?*
Have you ever used your title, position, rank, or company status to gain sexual favors?*
Have you ever been disciplined, suspended, or fired for losing your temper, or becoming hostile?*
Have you ever been disciplined, suspended, or fired for insubordination, defiance, or noncompliance?*
Have you ever been in a physical fight, hostile confrontation or loud argument with a supervisor, co-worker, or client/customer?*
Have you ever left a job with hard feelings toward the management, supervisors, or co-workers?*
Have you ever made a false allegation or false complaint against a supervisor, manager or director or co-worker?*
Have you ever been disciplined, suspended, or fired for lying or being untruthful?*
Has a citizen or customer complained to your employer about your attitude or behavior?*
Have you ever caused an injury to someone at work by your improper behavior?*
Have you ever counterfeited, forged, or dishonestly altered a timecard or time sheet to gain more money?*
Have you ever lied, made-up, fabricated, or misrepresented work hours or overtime?*
As an employee have you ever intentionally falsified a receipt, voucher, sales slip, or invoice?*
Have you ever stolen money from any employer?*
Have you ever stolen any property, equipment or material valued over $10 from an employer or kept extra pay you did not earn?*
Have you ever taken property, equipment or material from an employer and never returned it?*
Have you ever intentionally damaged property or equipment belonging to an employer or co-worker?*
Have you ever used any illegal narcotic during work hours or just prior to going to work?*

EXPERIENCE & EMPLOYMENT (continued)

Have you ever engaged in, participated in, or not reported, acts of racism or discrimination toward any supervisor, coworker, or client/customer?*
Have you participated in or not reported acts of sexual harassment or hazing toward any supervisor, coworker, or client/customer?*
Have you ever filed a bogus, false, or fictitious work injury report or filed a false workers compensation claim?*
Have you ever used a company computer to obtain restricted or unauthorized information for personal gain or for someone else?*
Have you ever intentionally deleted, altered, or destroyed company records to cause harm or disruption?*
Have you ever used a company computer to view unauthorized or prohibited websites on the Internet?*
Have you ever used a company computer to view restricted confidential records for personal reasons?*
Have you ever planted a computer virus with the intent of destroying company records or documents?*
Have you ever “called-in sick” when you were really well and not taking care of a sick family member?*
Has any supervisor, director, or employer ever spoken to you about being tardy or absent too often?*
Have you ever abandoned, quit, or left a job without giving proper two-week notice?*
Have you ever been fired from a job, released from probation, or asked to resign in lieu of termination?*
Has a bonding company ever turned you down?*
Have you ever been disciplined at work for any reason?*
Have you ever been found to be untruthful during a polygraph examination or voice stress analysis test?*
Have you ever falsified, withheld, or omitted information on any employment application?*
Have you ever received a verbal reprimand from any employer?*
Might a current or past supervisor or co-worker not recommend you?*
Have you ever received a written reprimand from any employer?*
Have you ever been counseled by any employer?*
Have you ever been charged disciplinary points in a point-based disciplinary system?*
Have you ever been disciplined, suspended, or fired from an employer for theft?*

EXPERIENCE & EMPLOYMENT (continued)

Have you ever been threatened with consequences, at work, for failure to complete work as directed?*
Have you ever been forced to or asked to resign from any employment?*
Have you ever been released during probation from any employment?*
Have you ever received an evaluation that was rated below standards or needs improvement?*
Have you ever engaged in any type or sexual activities (including masturbation) while at work or on company time?*
Have you ever been fired, terminated, laid off, or suspended from any employment?*
Is your version of how you left a job likely to differ from that of your employers?*
Have you ever had a complaint filed against you by a supervisor or coworker?*
Have you ever given a proper two-week notice but didn’t serve it out?*
Have you ever left a place of employment under unfavorable conditions?*
Have you ever abandoned, quit, or left a place of work to avoid being fired or suspended?*
Have you ever been investigated by an employer for improper conduct or illegal activity?*
Have you ever filed for or received unemployment benefits?*
Have you ever worked “under the table” for cash?*
Have you ever filed for or received workers compensation for a work-related injury that you were not entitled to?*
Have you ever caused an injury to another at work by your improper behavior?*
Have you ever counterfeited, forged, or dishonestly altered a timecard or time sheet to gain more money or non-monetary benefits?*

EXPERIENCE & EMPLOYMENT (continued)

Have you ever received pay you did not earn and kept it without reporting it?*
Have you ever operated your own business without properly obtaining a business license?*
Have you ever operated your own business without reporting your income on your tax return?*
As an employee, have you ever intentionally falsified a receipt, voucher, sales slip, or invoice?*
Have you ever intentionally falsified a warranty or service contract?*
Have you ever stolen money (cash, coins, checks, receipts, voucher, gift cards) from an employer or coworker (including from a cash drawer, box, register, or safe)?*
Have you ever been late to work?*
Have you ever allowed others to steal items, or cash, from any of your places of employment?*
Have you ever given away items from an employer without authorization?*
Have you ever reduced the cost of an item at work without authorization?*
Have you ever consumed alcoholic beverages at work or within six hours prior to scheduled work hours?*
Have you ever tested positive for an employment related drug test?*
Have you ever worked while under the influence of drugs (prescription or illegal) or alcohol?*
Have you ever returned to work from a break or lunch after consuming one or more alcoholic beverages?*
Have you ever used any illegal narcotic during work hours or within six hours prior to scheduled work hours?*
Have you ever provided confidential information from your employer to any unauthorized person?*
Have you ever had any extended work absences for any reason other than for medical or earned vacation?*
Have you ever been asked to resign or leave a volunteer or unpaid position?*
Have you ever retired, or resigned, to avoid investigation, prosecution, or discipline?*

EXPERIENCE & EMPLOYMENT – OTHER AGENCY APPLICATIONS

Have you ever previously applied to this agency, or any other, for a sworn and / or a civilian position?*
Agency*
Agency
Date Applied
Current Status
Position
Investigator
 
Have you ever applied to another government agency not listed on the previous question? This include any Police, Fire, Medical, Ambulance, or other Public Safety Agency.*
Agency*
Agency
Date Applied
Current Status
Position
Investigator
 
Have you ever been disqualified by this agency, or any other public safety agency for any reason?*
Have you ever worked for any public safety agency in any capacity?*
Have you ever withdrawn, waived or discontinued your application to a public safety agency because you knew or suspected that you were going to be non-selected or disqualified after you applied?*
Have you ever been rejected as a public safety candidate for intentionally lying, withholding information, or trying to deceive the agency?*
Have you ever been disqualified as a public safety candidate due to drug related issues?*
Have you ever been disqualified as a public safety candidate due to issues related to criminal activity?*
Have you ever worked for any fire department, EMS agency, and/or Ambulance Service in any capacity?*

MILITARY

Have you ever attempted to enlist in any military organization in this country or another?*
Have you ever been rejected or turned down by any military organization?*
Did you fail to register with the selective service as required (for men) at 18?*
Have you ever served in any military organization in this country?*
Organization*
Have you ever served in any military organization in another country?*
Country*
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Have you ever served in any military organization in this country or another?*
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Answer questions if you served in the military
Did you receive a discharge type that was not “Honorable?"*
Did you serve your full obligated term of service?*
Were you involuntarily discharged?*
Do you have any concern about an investigation into your activities or performance while in the military?*
If already discharged, and not retired, would the military decline you if you attempted to re-enlist?*
Did you ever receive a court martial?*
While in the military did you receive judicial punishment including written reprimands?*
While in the military did you receive any non-judicial punishment?*
While in the Military, did you ever receive written counseling for any action, inaction, or deficiency?*
Were you ever placed in military confinement or placed under military arrest or detention?*
Were you ever restricted to base as punishment for an improper act you committed?*
Were you ever restricted or confined to a military base, ship, quarters, or barracks?*
Were you ever reduced in grade or rank?*
Were you ever denied any type of security clearance?*
Did you ever use your position or rank in the military to gain sexual favors?*
Did you ever obtain classified information in an unauthorized manner?*
Did you ever participate or engage in racial or sexual discrimination in the military?*
Were you ever AWOL?*
Were you ever investigated by INS, DHA, ICE, Department of Defense, FBI, or military police for any illegal activity?*
Did you ever try, use, or experiment, any illegal drug or narcotic on or off a base?*
Have you ever failed to follow a lawful order from a Commissioned Officer or Non-Commissioned Officer?*
Did you ever steal, take, or keep military property without permission for personal use or to sell or give away?*
Did you ever cause injury to another person in the military due to negligence or carelessness?*
While in the military, did you ever do something that you knew was against military regulations that if caught you would be discharged or disciplined?*
Have you ever used deadly force while in the military?*
Have you ever served as a military police officer?*
Were you ever arrested, detained, or taken into custody by the military police?*
Were you ever contacted, questioned, or stopped by the military police or base security for inappropriate actions including traffic citations?*
Did you ever have, even temporarily, a security clearance revoked, suspended, or downgraded?*
Have you ever taken souvenirs from a combat environment and kept them for novelty?*

FINANCIAL

Have you ever filed or declared bankruptcy?*
Have you ever had your wages attached or garnished?*
Have you had a debt, account or loan turned over to a collection agency?*
Have you ever been delinquent or late on income taxes or other taxes?*
Are you now or have you ever been on a payment plan for paying any taxes, liens, or other judgments?*
Have you ever skipped out on any debt or financial obligation?*
Have you ever skipped out on paying rent by moving away?*
Have you ever used false information to apply for any credit?*
Have you ever intentionally filed a fictitious, false, or untrue tax return?*
Have you ever intentionally written a bad check?*
Have you ever taken money or benefits from a city, county, or federal government under false pretenses?*
Have you ever obtained and/or used a credit card, ATM card, debit card or check card illegally?*
Have you been late on child support payments?*
Have you ever opened a checking account, using a phony name or address?*
Have you ever borrowed money from a friend or relative with no intent of paying them back?*
Have you ever provided false information about your identity on a credit or loan application?*
Have you ever avoided paying any debt by moving away, changing your name or social security number?*
Have you ever been refused or skipped out on paying a student loan?*
Have you ever attempted or obtained financial gain through dishonest means or illegal acts?*
Have you ever collected unemployment benefits that you were not entitled to or through dishonest means or filed a false unemployment claim?*
Have you ever filed a false insurance claim to collect money or property?*
Have you ever loaned money to someone and threatened violence if they did not pay you?*
Have you ever borrowed money to pay a gambling debt?*
Have you ever participated in or took part in illegal gambling?*
Have you ever placed a bet on a sporting event for someone?*

FINANCIAL (continued)

Have you ever gambled with your income or savings while delinquent or behind on your financial obligations?*
Have you ever sold or bought a fictitious ATM, debit, or credit card?*
Have you ever been involved in money fraud or counterfeiting?*
Have you ever used a false, phony, or different social security number for any reason?*
Have you ever had a poor credit rating or credit report?*
Have you ever been sued over a debt?*
During your background is anyone likely to report that you have financial issues or do not manage your finances well?*
Have you ever filed or collected a false welfare or government assistance claim with any private or public organization?*
Have you ever had any property repossessed?*
Are there any civil actions pending in civil court in which you are a defendant?*
Do you currently have, or have you ever had any lien or judgment filed against you, your property, or any business of yours?*
Have you ever been delinquent or late on any of your monthly bills?*
Have you ever been late paying your rent or mortgage?*
Have you ever collected welfare?*
Have you ever collected food stamps?*
Have you ever had a government subsidized educational loan that became delinquent?*
Have you ever purposely avoided paying any debt or financial obligation?*
Are you currently required to pay court ordered restitution?*
Have you ever failed to make or been late on a court ordered payment (child support, alimony, restitution)?*
Have you ever refused to pay a court ordered payment (child support, alimony, restitution)?*
Have you ever attempted or committed fraud against a financial institution or bank?*
Are you delinquent or late on any of your credit card, loan, and/or revolving account payments?*
Have you ever been late with your credit card, loan, and/or revolving account payments?*
Have you ever failed to file an income tax return?*
Have you ever been investigated for filing a false tax return?*
Have you ever had all or part of your federal or state tax return withheld for any reason?*
Have you bought or sold an ATM, Debit, or Credit card that was in someone else's name?*

LEGAL

Have you ever been charged with a felony where the conviction was reduced to a lesser crime?*
Have you ever been charged with a misdemeanor where the conviction was reduced to a lesser crime?*
Have you ever been taken to a jail or a police holding room?*
Have you ever received a misdemeanor citation? (Citation in lieu of being booked)*
Have you ever been charged, arrested, or detained in another country?*
Have you ever been detained at a U.S. border for suspected illegal activity?*
Have you ever been charged, arrested, or detained for a hate crime?*
Have you ever committed a hate crime even if not caught?*
Have you ever been with someone who committed a hate crime?*
Are you ever engaged in or are you currently engaging in membership in a hate group, participating in any hate group activities, or advocate public expression of hate?*
Have you ever belonged to, or associated with, a subversive or militant group, alliance or organization that advocates racism or hatred toward others because of their way of life, background, culture, or customs?*
Have you ever delivered, sent, transmitted, disseminated, or mailed flyers, letters, bulletins, books, notices, photos, literature of any kind or electonically transmit to anyone containing racist or sexist information?*
Have you belonged, associated, or subscribed to any subversive or militant group or organization that advocates the use of aggression toward the U.S. Federal Government, state government or city government?*
Have you associated with someone, a group, alliance, association, club, or organization that despised certain cultures or types of people?*
Have you ever hit, struck, slapped, kicked, pushed, thrown or grabbed your spouse, girlfriend, boyfriend or significant other in anger or while involved in an argument at home or in public?*
Have you ever prevented or prohibited someone from making an emergency telephone call?*
Have you ever had a restraining order filed against you?*
Have you ever committed a violent assault upon another person (including spouse, significant others)?*
Have you ever struck, kicked, or injured someone living with you?*
Have you ever been a suspect, victim or witness to domestic violence?*
Have you ever lost your temper with your family, friends, co-workers, supervisors, or a stranger?*
Have you ever followed someone against their will, or stalked someone by following them secretly, furtively, or surreptitiously? (Stranger, someone you know, public figure or entertainer)*
Have you ever encouraged someone to lie to a law enforcement officer or lie while testifying in court?*

LEGAL (continued)

Have you ever knowingly filed a fictitious or false police report?*
Have you ever called in a false emergency to the police or fire department?*
Have you ever called a police or fire dispatcher and lied about your identity?*
Have you ever offered a bribe to a police officer, deputy sheriff, law enforcement officer or public official?*
Have you ever intentionally given false information to any police officer or other law enforcement officer?*
Have you ever lied or given false information to a court official, City Attorney, District Attorney or Judge?*
Have you ever lied while testifying in court?*
Have you ever threatened force or violence against a spouse, former spouse, relative, girlfriend, boyfriend, or anyone, including a stranger, who was going to be interviewed by the police or testify in court?*
Have you ever falsified or planted any evidence before, during or after a criminal or civil investigation?*
Have you ever threatened force or violence or attempted to intimidate a person serving on a jury?*
Have you injured or threatened to cause harm or injury to any law enforcement officer?*
Have you ever run from any police officer or law enforcement official?*
Have you ever resisted arrest or fought with a police officer, or law enforcement officer?*
Have you ever assisted someone to escape from police custody, detention or jail?*
Have you ever protected a person or fugitive from arrest or questioning?*
Have you ever covered-up a crime or mislead any public official for someone?*
Have you ever pretended to be a law enforcement officer with the intent of misleading someone in order to obtain personal information or confidential information?*
Have you ever pretended to be a law enforcement officer with the intent of misleading someone in order to detain, confine, restrict, arrest or scare someone?*
Have you ever blackmailed someone? (Forced someone to do something because you had knowledge or leverage that could embarrass them or get them in trouble)*
Have you ever modified or equipped your vehicle to represent an emergency vehicle to mislead someone?*
Have you ever been accused of, or questioned about child abuse, child neglect or child molestation?*
Have you ever injured or bruised a child because of losing your temper or by using corporal punishment?*

LEGAL (continued)

Have you ever ignored someone committing what you thought was child abuse, neglect, or molestation?*
Have you ever tied up a child, or locked up a child in a small, confined space to discipline the child?*
Have you ever disciplined a child by placing a child into a dangerous or unsafe situation where the child could be injured or hurt because of losing your temper or administering discipline?*
Have you ever left or abandoned a child or children without proper care or proper supervision?*
Have you ever used your child or children as leverage to force the other parent to do something against their will?*
Have you ever taken your child or children against the will of the other parent?*
Have you ever violated a child custody court order?*
Have you ever refused or intentionally delayed your obligation to pay child support?*
Have you ever falsified any school record regarding the identity of your child or children?*
Have you ever been involved in a physical fight with someone?*
Have you ever assaulted someone in anger using a bat, club, stick, pipe, or other hard object?*
Have you ever used a knife, dagger, or other stabbing instrument against someone in anger or defense?*
Have you ever brandished or pointed a firearm in a threatening or rude angry manner at someone?*
Have you ever fired a firearm illegally at a house, building, apartment, vehicle, vessel or aircraft?*
Have you ever fired a firearm at someone or used it to scare or intimidate them?*
Have you ever carried a concealed firearm on your person without a lawful permit?*
Have you ever been in a vehicle where someone else discharged a firearm?*
Have you ever purchased, constructed, or attempted to construct a bomb or explosive?*
Have you ever associated a person, or group of persons, who constructed a bomb or explosive?*
Have you ever been a gang member or associated with gang members?*
Do you currently have any friends, family members or associates that are currently gang members?*
Do you currently have or ever had any gang tattoos or monikers?*
Have you ever assisted or cover up any crime committed by a gang member.*
Have you ever committed any graffiti, tagging, or similar act?*
Have you ever stolen money? (Cash, money orders, checks, bank notes, etc.)*

LEGAL (continued)

Have you ever stolen electronic equipment? (TV’s, stereo’s, computers, cellphone, etc)*
Have you ever stolen a purse, wallet, briefcase, jewelry, suitcase, or similar items?*
Have you ever bought, maintained, or kept property, knowing or believing it was stolen or illegally obtained?*
Have you ever stolen money? (Cash, money orders, checks, bank notes, etc.)*
Have you ever committed a theft by using a mask or disguise or by using a weapon?*
Have you ever stolen a vehicle or taken a vehicle without the owner’s permission?*
Have you ever associated with or been a member of a street racing club or outlaw motorcycle club / gang?*
Have you ever kept a vehicle longer than was agreed to, without the owner’s permission?*
Have you ever committed a theft by taking an item directly from a person?*
Have you ever committed a theft by breaking into a car or taking something from an open or unlocked car?*
Have you ever stolen car parts?*
Have you ever committed shoplifting, including the switching of price tags or not scanning items at self checkout?*
Have you ever entered a house, garage, building, or other dwelling to commit a theft?*
Have you ever used a weapon, applied force or fear, to steal something from someone?*
Have you ever made harassing, annoying, or threatening telephone calls to anyone?*
Have you ever had to testify in a criminal or civil proceeding?*
Have you ever had your conviction records sealed, dismissed, or expunged?*
Have you ever had your vehicle searched by law enforcement or any governmental agency?*
Have you ever violated a restraining order?*
Have you ever fraudulently altered any type of document?*
Have you ever been accused of any crime?*
Have you ever had a warrant issued for your arrest?*
Have you ever been detained or questioned (stopped/held) by police?*
Have you ever given false information to a police officer, security officer, or loss prevention officer?*
Have you ever been arrested?*

LEGAL (continued)

Have you ever been handcuffed by police?*
Have the police ever been called regarding an incident you were involved in?*
Have you ever been to court for anything other than a traffic citation?*
Are you currently under investigation by any law enforcement agency for any reason?*
Have you ever violated a condition of probation?*
Have you ever been on probation?*
Have you ever participated in a riot, protest, or demonstration?*
Have you ever broken into a house, school, business, or other building?*
Have you ever harmed or caused injury to anyone?*
Have you ever accepted a bribe of any type?*
Have you ever taken or kept money or other valuable entrusted to you?*
Have you ever committed any type of fraud?*
Have you ever threatened anyone with physical violence?*
Have you ever trespassed on any property?*
Have you ever vandalized, damaged, or destroyed property?*
Have you ever committed robbery?*
Have you ever committed burglary?*
Have you ever kidnapped anyone?*
Have you ever killed or attempted to kill anyone?*
Have you ever stolen anything after the age of 14?*
Have you ever illegally shared or spliced into someone else’s cable, internet service, or other utilities?*
Have you ever eaten at a restaurant and left without paying?*
Have you ever used someone else’s social security number?*
Have you ever taken or used someone else’s credit card or credit card number without their permission?*
Have you ever purchased, manufactured, or otherwise obtained or used a fictitious/forged identification or used another person’s identification for any purpose?*
Have you ever kept found property that did not belong to you?*
Have you ever been with someone when they committed a crime?*

LEGAL – PERSONAL BEHAVIOR

Sexual activity includes any and all sex acts, including intercourse, oral copulation, phone sex, cybersex, masturbation, fondling or any related type of sex act.
Have you ever used or solicited the services of a prostitute inside or outside the United States?*
Have you ever committed prostitution (received money, drugs, or property for any sexual act)?*
Have you ever used a prostitute who was under the age of 18 or who you suspected of being under the age of 18?*
Have you ever been to a strip club (if “yes”, how many times and when was the last time)?*
Have you ever been to a function where a stripper performed?*
Have you ever solicited any lewd act in a public place?*
Have you ever derived any financial support by soliciting prostitution for prostitutes (pimping)?*
Have you ever encouraged or recruited persons to be a prostitute (pandering)?*
Have you ever used any type of drug or narcotic or any type of intoxicating chemical to seduce or overpower someone to have sex with you knowing it was without their permission?*
Have you ever coerced or tricked someone to have sex with you or someone else without his or her consent?*
Since the age of 18, have you ever had sex with someone under the age of 18 or who you suspected, or claimed to be under the age of 18?*
Have you ever had a dating or sexual relationship with anyone related to you?*
Have you ever forced a person to have sex with you and/or someone else?*
Have you ever had sex with a relative or member of your family other than your spouse?*
Have you ever viewed, purchased, sold, participated or subscribed to child pornography or animated child porn?*
Have you ever had sexual contact with a child (fondling, taking pornographic pictures, masturbating in a child’s presence, oral sex, sexual intercourse, etc.)?*
Have you ever illegally exposed yourself (genitals) to anyone?*
Have you ever had sex or masturbated in a public place or in public view? i.e. movie theater, restroom, park, dressing room, or any other place open to the public including parked cars?*
Have you ever made any annoying, harassing, obscene or crude phone calls to anyone?*
Have you ever attempted to commit any of the above acts?*
Have you ever been labeled as, or had to register as, a sex offender?*
Have you ever participated in any form of sex-related entertainment which you are concerned about in this investigation?*
Have you ever participated in any sexual act, or been aroused, related to having sex with an animal?*
Have you ever looked into any window or opening to invade someone’s privacy?*
Have you ever intentionally started a fire to cause property damage or to injure someone?*

LEGAL – PERSONAL BEHAVIOR (continued)

Have you ever tortured, maimed, beaten or brutally killed an animal or pet?*
Have you ever tormented, mistreated, neglected, or abused an animal or pet?*
Have you ever placed any animal or pet in a dangerous or risky situation knowing the animal or pet could be injured or killed (including dog, cockfighting, and any other animal gaming)?*
Have you ever had any family problems because of gambling?*
Have you ever had any employment problems because of gambling?*
Have you ever had to borrow money to gamble?*
Have you ever illegally damaged or destroyed property or committed any acts of malicious mischief which resulted in damaged property?*
Have you ever mentally or emotionally abused someone in an intimate relationship (called them harmful names, threatened, humiliated, insulted or terrorized them, intentionally tried to hurt their feelings or make them feel bad)?*
Do you currently associate with persons whom you know to have engaged in and/or have been arrested for any unlawful activity; this includes anyone who is currently on parole or probation?*
Have you ever sexually or inappropriately touched anyone without their permission?*
Have you ever committed any physical sex act with any person who may have been too intoxicated (drugs or alcohol) to give consent or was unconscious?*
Have you ever had sexual intercourse with someone who did not expressly give consent or gave consent under the threat of force or violence to them or another?*
Have you ever had any sexual contact with a dead person?*
Have you ever viewed nude photos or videos of anyone under the age of 18?*
Have you ever bought, sold, traded, or taken photographs or videos of a nude or semi-nude person under the age of 18?*
Have you ever communicated or attempted to communicate with anyone under the age of 18 online, other than relatives?*
Have you ever visited any chat rooms, or websites, to buy, sell, or trade photographs or videos of a nude or semi-nude person under the age of 18?*
Have you ever attempted any of the criminal acts listed in this section (Legal)?*

LEGAL – ELECTRONIC COMMUNICATIONS

Have you ever damaged a cellphone, telephone or telephone line to prevent someone from calling for help?*
Have you ever planted a computer virus, key logging software, Trojan horse, or anything else similar?*
Have you ever intentionally disabled any communication system to prevent someone from accessing help?*
Have you ever committed an illegal electronic fund transfer?*
Have you ever used a computer to obtain illegal, unlawful, unauthorized, or prohibited information for you or someone else?*
Have you ever used the Internet to obtain information for the purposes of committing a crime or illegal act?*
Have you ever committed electronic eavesdropping through a computer network system?*
Have you ever used the Internet to view child pornography and / or animated child porn?*
Have you ever sent indecent, obscene, or offensive e-mail, text message, or via any App to someone without their consent or approval?*
Have you ever sent messages threatening some type of violence or harm via e-mail, fax, pager, text, or other electronic device?*
Have you ever sent racist or sexual discrimination information via e-mail, fax, pager, text message, App, or another electronic device?*
Have you ever posted unwanted sexual or nude photos of yourself, or any other person, on any social media site, blog, or any website?*
Have you ever sent unwanted sexual or nude photos of yourself, or any other person, via email, fax, or other electronic device?*
Have you ever obtained confidential or restricted information from a computer to sell it for profit?*
Have you ever given a friend, relative, or other unauthorized person, restricted or confidential information that you obtained and knew was against employment regulations or federal, or state laws?*
Have you ever sent a threatening e-mail, page, text message, App, or fax to a government official, politician, or public official?*
Have you ever disabled an alarm system for the purpose of committing a crime?*
Have you ever used a computer for the purposes of destroying, damaging or creating a disruption to another computer network or system, database or records for fun or because of anger (hacking)?*
Have you ever intentionally deleted, altered, or destroyed company records to cause harm or disruption?*
Have you ever sexually harassed anyone using social media?*
Have you ever hacked into any computer system or database?*
Have you ever used an application, or device, to monitor someone else’s communications or whereabouts without thier knowledge?*
Have you ever downloaded any program or any file (song, movie, streaming show, etc.) illegally?*
Have you ever obtained any computer parts illegally?*

LEGAL – ELECTRONIC COMMUNICATIONS (continued)

Have you ever obtained confidential or restricted information from a computer to sell it for profit?*
In the last 5 years, have you deleted or deactivated any of your social media accounts?*
In the last 5 years, have you deleted any posts or photos on any of your social media accounts because you thought they might reflect poorly upon you during the background process?*
Have you ever bullied anyone on any social media site?*
Have you ever bullied anyone via email, text message, or any app?*
Have you made any social media posts that could be interpreted as biased against any person or group?*
Do you use any vanishing/disappearing chat or secret chat on any social media platform?*

LEGAL – NARCOTICS

Have you ever ingested or injected any form of steroids?*
Have you ever purchased steroids for you or someone else?*
Have you ever injected or had someone inject, any illegal drug, narcotic or chemical into your body?*
Have you ever given or sold any type of illegal substance, chemical, drug or narcotic to anyone?*
Have you ever sold or provided any chemical compound or element to someone, knowing the purpose was to manufacture an illegal substance, designer drug, narcotic or similar product?*
Have you ever manufactured any illegal drug, narcotic, designer drug, or illegal substance or chemical?*
Have you ever transported any illegal drug, or narcotic?*
Have you ever remained in a private place illegal drugs, narcotics, designer drugs, rave drugs or any illegal substances were being used?*
Have you allowed someone to use illegal drugs, narcotics, or any illegal substance in your home or vehicle?*
Have you associated with friends, acquaintances or roommates who use illegal drugs or narcotics?*
Have you associated with relatives or family members who use illegal drugs or narcotics?*
Have you ever forged a prescription in order to obtain a drug or narcotic for you or someone else?*
Have you ever attempted to obtain a prescription drug or narcotic knowing the prescription was forged?*
Have you ever taken any prescription drugs that were not prescribed to you by a doctor?*
Have you ever abused or misused any prescription drug?*
Have you ever sold any prescription drug for any reason?*

LEGAL – NARCOTICS (continued)

Have you ever purchased or been involved in an illegal drug transaction, or transportation of illegal drugs?*
Have you ever ingested a substance you thought was an illegal drug and then found out it was not?*
Have you ever acted as a “middleman” for any drug transaction?*
Has someone given you an illegal drug or narcotic as a joke?*
Have you ever tested positive on any drug test (employment or other)?*
Have you ever had to register as a narcotic offender?*
Do any of your current friends or family use illegal drugs?*
Are there any illegal drugs, narcotics or paraphernalia in your home, vehicle or property that can be associated with you (even though they may belong to someone else)?*
Have you ever used or experimented any substances, drugs, or narcotics, even one time? (Do not include Marijuana)*
Have you ever tried any other substance, chemical or organic, legal or not, with the intent to get high? (Do not include Marijuana)*
Have you ever operated a motor vehicle while you were under the influence of narcotics or drugs?*
Have you ever worked under the influence of illegal drugs, narcotics, or controlled substance(s)?*
Have you ever had illegal drugs in your possession while at work?*
Have you traveled outside of the United State and purchased a drug or narcotic?*
Have you ever attempted any of the above acts listed in the LEGAL – NARCOTICS section?*

Have you ever used Cocaine?*
Have you ever used Cocaine powder?*
Have you ever used Crack?*
Have you ever used Rock Cocaine?*
Have you ever used Barbiturates (downers)?*
Have you ever used Amphetamines (speed, meth, ICE)?*
Have you ever used Heroin?*
Have you ever used Mushrooms?*
Have you ever used LSD?*
Have you ever used Other Hallucinogenic?*
Have you ever used PCP (angel dust)?*
Have you ever used Opium / Fentanyl?*
Have you ever used Morphine?*
Have you ever used Steroids or Human Growth Hormone (HGH)?*
Have you ever used Toluene, Glue?*
Have you ever used Designer / Synthetics (Ecstasy, Molly, MDMA, THB, etc)?*
Have you ever used Nitrous Oxide (Whippets)?*
Have you ever used GHB / Date Rape Drugs?*
Have you ever used Salvia Divinorum?*

Have you tried, used, or experimented with any other illegal drugs not listed above?*

MOTOR VEHICLE

During our investigation is anyone likely to report that you have problems with your driving?*
Has your driver’s license ever been suspended or revoked by any state?*
Have you ever been refused a driver’s license from any state?*
Have you ever drove off or fled the scene of a traffic accident or collision?*
Have you ever intentionally driven in a carpool lane when you didn’t have enough passengers?*
Have you ever been involved in a fight, altercation, confrontation, argument, quarrel or exchange of hand gestures with another motorist while driving?*
In anger, have you ever followed or chased another vehicle attempting to confront another motorist?*
Have you ever forced, or attempted to force, a motorist, bicyclist, or pedestrian off the road?*
Have you ever intentionally used your vehicle to force another driver to take sudden evasive action to avoid an accident, stop suddenly or to become involved in a traffic collision?*
While driving or sitting in a vehicle, have you ever pointed, displayed, or simulated a fake or real firearm at someone?*
Have you ever been involved in a speed contest or road race on a public street or highway as a driver, passenger, or spectator?*
Have you ever forced, pushed, or shoved a passenger out of a moving vehicle?*
Have you ever driven on a suspended, revoked, expired, or invalid driver’s license?*
Have you ever driven without being licensed to operate a motor vehicle or motorcycle?*
Have you ever made, altered, used or purchased a false driver’s license or state I.D. card?*
Have you ever misrepresented or misused a driver’s license or state I.D. card?*
Have you ever given, submitted, or provided false information, including a false address, date of birth or name to any Department of Motor Vehicles in any state?*
Have you ever filed or reported a false auto insurance claim, including a false collision report or stolen car?*
Have you ever caused an injury or death to someone because of your driving?*
Have you ever driven a vehicle faster than 90 miles per hour on any public highway, city, or county road?*
Have you ever used or attempted the use of disabled placards, licenses, etc., to illegally park?*
Have you ever driven without or been denied auto insurance?*
Reference your California driver's License, mark yes if any of the following apply: You do not have one, was never issued one, never applied for one, ID card only, suspended, or revoked.*
Have you ever applied for a driver’s license under a different name?*

MOTOR VEHICLE (continued)

Have you ever been issued a driver’s license in another state?*
Have you ever been issued a driver’s license in another country?*
Have you ever driven “out of class” (i.e. – driving a motorcycle without an M1 endorsement, driving a commercial vehicle with a Class “C” license.)?*
Have you ever driven a motor vehicle without insurance?*
Has your insurance ever been cancelled or been placed into a “high risk” category?*
Have you ever received a traffic citation for a moving violation or equipment violation?*
Have you ever attended traffic violator’s school?*
Have you ever failed to appear in court regarding a traffic citation you received?*
Have you ever failed to pay a traffic fine?*
Have you ever lied to avoid receiving a traffic citation or lied in court to avoid a guilty verdict?*
Do you have any outstanding traffic citations?*
Do you have any unpaid parking citations?*
Have you ever intentionally driven through a toll plaza or toll road without paying the toll?*
Have you ever been in any traffic collisions, whether they were required to have been reported or not?*
Have you ever driven a motor vehicle that was not currently registered?*
Have you ever made, changed, altered, used, or purchased false license plates, tabs, or papers?*
Have you ever removed or failed to attach license plates to a vehicle in order to avoid being identified?*
Have you ever watched or assisted in a speed contest or illegal road race on a public roadway or highway?*

MOTOR VEHICLE (continued)

Have you ever been cited for an equipment violation and failed to correct it?*
Have you ever been cited for an equipment violation, corrected the violation, and then returned the vehicle to its former illegal status?*
Have you ever maintained your vehicle registered in another state while living/working in California?*
Have you ever driven a vehicle with an open container of alcohol or allowed a passenger to possess an open container of alcohol?*
Have you ever driven a vehicle while under the influence of an intoxicating substance (i.e. – alcohol, illicit drugs, or prescription medications)?*
Have you ever driven a vehicle when you believed that if you had been contacted by law enforcement, you possibly could have been arrested for DUI?*
Have you ever been stopped by an officer and been given a verbal warning for a driving or mechanical violation?*
Have you ever been stopped by an officer for a moving violation and issued a citation for a lesser offense?*
Have you ever been in a vehicle that was fleeing from or evading law enforcement?*
Have you ever been the driver of a “getaway” vehicle?*
Have you ever been in a vehicle in which you or any other person discharged a firearm?*
Have you ever been in a vehicle in which you or any other person threw any object from the vehicle while it was in motion?*
Have you ever been placed on probation for a traffic related offense?*
Is your driver’s license under any current restriction or limitation?*
Have you ever been convicted of “reckless” or “wet reckless” driving?*
Have you ever had a traffic citation dismissed because the officer failed to show at court?*

OTHER TOPICS – INTOXICATING SUBSTANCES

Have you ever been arrested for driving under the influence of any drug or alcohol?*
Have you ever driven while under the influence of an alcoholic beverage or narcotic?*
Have you ever “called-in sick” to work when you were hung over?*
Have you ever purchased, supplied or served alcohol to a minor?*
Have you ever purchased alcohol when you were under the legal age to purchase alcohol?*
Have you ever used a fictitious/forged identification or used another person’s identification to purchase alcohol?*
Have you ever been publicly intoxicated and were unable to care for yourself?*
Have you ever been asked to leave an establishment because of your alcohol consumption?*
Have you ever been refused to be served due to your alcohol consumption?*
Have you been in trouble or been warned on the job because of drinking an alcoholic beverage?*
Have you ever been terminated for drinking alcoholic beverages on or off the job?*
Have you ever been told by your spouse or family that you drink too much?*
Is anyone likely to report that you have had problems related to alcohol?*
Have you ever done anything illegal after alcohol consumption?*
Have you ever stolen alcohol?*
Have you ever consumed alcoholic beverages while as a passenger or driver in a vehicle?*
Have you ever “blacked out” after consuming alcohol?*
Have you ever possessed and/or consumed alcohol under the age of 21?*
Have you ever possessed and/or consumed marijuana under the age of 21?*
Have you ever driven a motor vehicle under the influence of marijuana?*
Have you ever used marijuana during work hours*
Have you ever gone to work under the influence of marijuana*

OTHER TOPICS – APPLICANTS FOR PUBLIC SAFETY POSITIONS

Those who are applying for a public safety position (to include peace officers, reserve peace officers, dispatchers, firefighter, CSOs, Evidence Technicians) must answer the following questions.
Would you be reluctant, or refuse, to enforce any laws, in whole or in part?*
Might someone tell us you lack the interpersonal skills to be a public safety official?*
Might someone tell us you are unable to physically handle the duties required for a public safety official?*
Have you ever cheated on a public safety examination, including a physical abilities test?*
Are you concerned that you may not meet one or more of the minimum qualifications for a public safety position?*
Have you ever failed or dropped out of any public safety academy or training class?*
Have you ever been rejected as a public safety candidate for intentionally lying, withholding information, or trying to deceive the agency?*
Have you ever been disqualified as a public safety candidate due to drug related issues?*
Have you ever been disqualified as a public safety candidate due to issues related to criminal activity?*
Have you ever used or are you familiar with using a firearm?*
Are you afraid or concerned about using a firearm?*
Would you be unwilling, or unable, to use physical force if necessary and lawful?*
Would you be unwilling, or unable, to use lethal force if necessary and lawful?*
As a peace officer, you are expected to enforce the law impartially. Would you ever make an exception for a friend or acquaintance using illegal drugs?*
Are you afraid of physical combat?*

OTHER TOPICS – LATERAL PUBLIC SAFETY QUESTIONS (PRIOR PUBLIC SAFETY EMPLOYEE)

Details for “Yes” responses to the following questions must include date(s), agency name(s), name(s) of other(s)/officer(s), location(s), case number(s), and disposition(s).
As a public safety employee, have you ever accepted a gratuity?*
As a public safety employee, have you ever accepted anything for overlooking a violation?*
As a public safety employee, have you ever intentionally made a false official report?*
As a public safety employee, have you ever used your official position for personal gain?*
As a public safety employee, have you ever withheld evidence seized in the course of your official duties?*
As a public safety employee, have you ever had sex while on duty with anyone?*
As a public safety employee, have you ever used any illegal or controlled drugs?*
As a public safety employee, did you ever drink alcohol while on duty?*
Have you ever intentionally lied, withheld information, or deceived any law enforcement agency?*
As a public safety employee, have you ever stolen from a prisoner or detainee?*
As a public safety employee, have you ever taken cash, property, or valuables from a dead body?*
As a public safety employee, have you ever taken cash, property, or valuables from an intoxicated person?*
As a public safety employee, have you ever exposed the identity of a confidential informant?*
Have you ever exposed the identity of an undercover peace officer?*
Have you ever used your department’s resources or criminal databases including computers, CLETS, etc., for personal or non-offical use?*
Have you ever shared confidential information including documents, photos, videos, or other evidence to the press or unauthorized persons?*
Have you ever taken, or received, photos at a crime scene and sent them via text or posted them on a social media website or on the internet?*
Have you ever had an on-duty contact turn into a personal relationship?*
While on-duty, have you ever carried an unauthorized weapon or unapproved ammunition?*
Have you ever been involved in a shooting incident?*
While on-duty, other than on a firing range, did you ever fire your weapon (including accidental discharges)?*
Did you ever date a citizen or former inmate, suspect, or defendant that you met while on duty?*
Have you ever written poor or useless citations to appease your supervisor or to meet a required performance standard?*
Have you ever slept while on-duty?*
Have you ever been placed on administrative leave?*
Have you ever given false testimony in court, administrative hearing, or other official proceeding?*
Have you ever made a false statement in or omitted significant information from a police or other official document?*

OTHER TOPICS – LATERAL PUBLIC SAFETY QUESTIONS (PRIOR PUBLIC SAFETY EMPLOYEE) (continued)

As a public safety employee, have you ever been the subject of an internal affairs investigation?*
As a public safety employee, have you ever had a citizen's complaint alleged against you?*
Have you ever had any disciplinary actions taken against you, including suspensions, written and oral reprimands (including military and reserve peace officer experience)?*
Have you ever been involved in an incident where it was necessary to use deadly force, regardless of whether the person died or not (including military and reserve peace officer experience)?*
As a public safety employee, have you ever been involved in any relationship with a prisoner, inmate, or detainee in or out of custody?*
As a public safety employee, have you ever testified in a criminal or civil proceeding? List each county.*
As a public safety employee, have you been involved in any on-duty traffic accidents, where you were the driver (regardless of who was at fault)?*
Were you ever the subject of a civil suit or criminal prosecution, because of your actions as a public safety employee?*
As a public safety employee, have you ever had any unsatisfactory personnel ratings (including ratings of improvement needed)? Do not count ratings received during probation.*
As a public safety employee, were you ever accused of committing perjury?*
As a public safety employee, did you ever lie or seriously distort the facts in an official report?*
As a public safety employee, did you ever cover up a serious incident for a fellow officer?*
As a public safety employee, did you ever lie or commit perjury in any court or other official proceedings?*
Were you ever terminated or forced to resign from a public safety position during the probation period?*
Were you ever terminated or forced to resign from a public safety position after probationary period?*
Did you ever use excessive force, or were you ever accused of it?*
Did you ever keep for yourself any found or lost property or any evidence?*
Have you ever failed any POST training (modules, Academy, specialization)?*
As a public safety employee, have you ever been placed on a Brady list? If yes, list each county.*
Have you ever had to attend training to correct a training deficiency?*
Have you ever been reassigned for reasons relating to substandard performance, unacceptable conduct, or under any other adverse circumstance?*
Have you ever given false information during any official criminal or administrative inquiry or investigation?*
Is there anyone in a public safety agency where you have been employed who might not recommend you for the position?*
Is there anyone in any public safety agency where you have been employed who might not give an objective assessment of your qualifications?*

OTHER TOPICS – LATERAL FIRE / EMS QUESTIONS (PRIOR FIRE / EMS / AMBULANCE EMPLOYEE)

Have you ever completed a fire academy?*
MM slash DD slash YYYY
Have you completed the FCTC Candidate Physical Ability Test (CPAT)?*
MM slash DD slash YYYY
Have you ever taken unauthorized photos or video on an emergency scene while on duty?*
Have you ever posted unauthorized photos or videos of an emergency scene on social media or other online platforms?*
Have you ever been disciplined by an employer for social media or other online platform posts?*
While on duty, have you ever accepted free drinks or discounted meals?*
Have you ever kept lost or found items you came across while providing emergency services?*
Have you ever provided information to the news media without authorization?*
Have you ever stolen anything from a medical, fire, or collision scene?*
Have you ever taken medications, I.V. supplies or other medical supplies for use beyond your scope or practice or in the use of your employment?*
Have you ever started an Intravenous solution on anyone (including yourself) outside of your scope of practice or course of employment?*
Has your EMT and/or Paramedic License ever been on probation or suspended?*
Are you certified with California EMSA as an Emergency Medical Technician?*
MM slash DD slash YYYY
Are you certified with the National Registry of EMTs as an Emergency Medical Technician and/or Paramedic?*
MM slash DD slash YYYY
Are you currently accredited to work as an EMT and/or Paramedic?*
Do you have a current American Heart Association CPR card?*
MM slash DD slash YYYY
Have you ever taken medical supplies or materials from an ambulance or firefighting vehicle?*
Have you ever taken any first aid supplies, saline bags, or paramedic supplies for use beyond authorized work responsibilities?*
Have you ever operated outside of the scope of your EMT and/or Paramedic certification by administering IV solutions to a friend or family off-duty?*
Have you ever had sex while on duty?*
Have you ever had sex in/or on an ambulance or firefighting vehicle?*
Have you ever lied or misrepresented your location to dispatch to avoid assignment for an emergency response?*
Have you ever, or been accused of releasing HIPAA-protected information?*
Have you ever been involved, as the driver, in a vehicle collision in an ambulance or firefighting vehicle?*
Have you ever carried an unauthorized firearm while working as a firefighter, EMT, or Paramedic?*
Have you ever been accused of violent or physical mistreatment of a patient in the course of your employment?*
Have you ever taken or kept prescription medication, belonging to someone else, obtained in the course of your employment?*
Have you ever intentionally falsified information on a Patient Care Report for any reason?*
Have you ever been questioned or investigated as part of an employer’s “Drug diversion program”?*
Have you ever personally used any medication intended for emergency use for personal unauthorized use?*
Have you ever recorded someone (either audio or video) without their permission while transporting in the back of an ambulance?*
Have you ever been disciplined or reprimanded for the loss or damage of firefighting or EMS equipment?*
Have you ever used agency computer access to obtain unauthorized information about another individual?*
Have you ever been accused or disciplined for “Insubordination”?*
As an EMT and/or Paramedic have you ever operated, outside your “scope of practice”, because you felt it was medically prudent?*
Have you ever used information received as part of an official report for personal reasons?*

Details

With regard to your most recent assignment within the above-named agency, please provide the following information
MM slash DD slash YYYY

Please list all your assignments within your agency for the past sixty (60) months. Include special and/or temporary assignments, e.g., SWAT, honor guard, reserve officer coordinator, etc.
List of all the assignments*
Dates Mo/Yr to Mo/Yr
Assignment (Division, Bureau, Detail, etc.)
Immediate Supervisor
Current phone number (+Email)
 

OTHER TOPICS – MISCELLANEOUS

Have you ever omitted any information in any of your applications or questionnaires?*
Have you been forthright in all your answers in the application process?*
Have you intentionally omitted any adverse information or facts in any of your information that you have provided?*
Is there anything you have not been asked that could be considered negative or adverse and might eliminate you from consideration for this job?*
Have you ever applied for a permit to carry a concealed weapon?*
Are you prohibited by law from owning, possessing, or carrying a firearm?*
Do you own any type of firearms or any weapons?*
Are you withholding any information in your background that could be potentially disqualifying or could be embarrassing to you or the agency to which you are applying, if discovered?*
Is there anything that you did not list on this questionnaire that you believe background investigators, and the agency to which you are applying, should be made aware of?*
If you are given a job offer, will your acceptance be contingent on the job assignment that you will be given or on any other specific condition of employment?*

Acknowledgment

I am aware that any false statements or omissions made on this questionnaire may cause my name to be removed from the eligibility list or be cause for non-selection by the hiring agency.

I understand that I am subject to termination if discrepancies are discovered after I have been appointed.

Additionally, I understand that I am to immediately notify my background investigator of any changes in the information in this document.

I understand that failure to notify the background investigator of these changes as soon as possible could also be grounds for disqualification and / or non-selection.

I acknowledge that these records are confidential and will be the property of the hiring authority.

I have been warned to not sign unless I have answered all questions truthfully.

I hereby certify that all statements made in this questionnaire are true and complete.
Clear Signature
MM slash DD slash YYYY

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