Revised June 2014
KENTUCKY LAW ENFORCEMENT
C
OUNCIL
Peace Officer Professional Standards
Telecommunicator Professional Standards
Court Security Professional Standards
PRE-EMPLOYMENT
Polygraph Questionnaire
FORM I-2
APPLICANT
NAME:
Agency applying with:
Position applying for:
Date of Examination:
Assigned Time:
Testing Site:
GENERAL
INSTRUCTIONS:
This questionnai
re should be completed PRIOR to arriving at the test site. Please give this form to the
examiner on the day of testing. If it is incomplete, the exam may be rescheduled.
Drug testing is customarily administered on the same day as polygraph examinations. If your agency has
scheduled you for a drug screen, please arrive to the test site prepared to give a urinalysis sample.
Agencies must notify the KLEC office of cancellations a minimum of 24 hours in advance to avoid being
charged a No Show fee. Notify your agency if you do not intend to keep your appointment.
Call the KLEC office at 859-622-6218 on the day of your appointment if you are running late or are lost.
2
INSTRUCTIONS TO JOB
APPLICANT
Before completing the following questionnaire, it is important for you to understand the
purpose of
the polygraph examination you will be taking. Law enforcement officials are expected to
have a
high degree of honesty and integrity. If law enforcement agencies only hired people who had
never made a mistake, done anything wrong, nor ever committed a crime, there would be no
one in
law enforcement positions. There are no perfect people.
The purpose of this questionnaire and the forthcoming polygraph examination is not to find the
perfect person. This questionnaire and the polygraph examination have been designed to assist in
identifying the honest person. Agencies seek people they can trust.
No law enforcement agency should hire someone that cannot be trusted. Your word is your bond.
The law enforcement community, the court systems, and society as a whole must be able to trust
their law enforcement officials. As you fill out this questionnaire, above all – be honest.
•
While completing the questionnaire, answer all questions to the best of your ability. It is
understood that no one can remember every detail or every exact date, but again, aim to
answer to the best of your ability.
•
If you do not understand a question, do not answer it. Put an asterisk (*) by the question
number. The polygraph examiner will explain the question.
•
The polygraph examiner will explain the process in detail. If you have questions, you will
be given an opportunity to address those with your examiner. It is important that you
discuss any concerns or questions prior to the polygraph examination.
•
Do not lie in this questionnaire. Do not lie in the polygraph examination
procedure.
•
Lying is an intentional act. Do not intentionally leave out information. Do not
intentionally misrepresent information.
Write in black or blue ink. Make comments as needed and write on the backside of these pages
when necessary.
3
PERSONAL INFORMATION:
Full Legal Name:
(First) (Middle) (Last)
Date
of
Birth:
Age:
Soc.
Security
#:
- _-
Place of Birth:
(City/State/County)
Current Address:
(Street) (City) (State) (Zip)
How
long
living
at
current
address?:
Home
phone
number:
(
)
-
List
all
other
states
and/or
countries
in
which
you
have
lived:
Have y
ou ever used a different name? Yes No
Have you ever used a different social security number? Yes No
Have you ever used a different date of birth? Yes No
Are you a U.S. citizen? Yes No
If yes, please check one: U.S. born
U.S.
naturalized
Other:
Marital Status: Single
Married
Divorced
Separated
Other:
Have you ever taken a polygraph or other type of honesty test? Yes No
If “yes”: 1.)
(Year) (Agency that administered test) (Purpose or Reason)
2.)_
(Year) (Agency that administered test) (Purpose or Reason)
4
EDUCATION:
G.E.D.? Yes No Name of school:
Year Obtained:
High School Graduate? Yes No Name of school:
Year Graduated:
2-Year College Degree? Yes No Name of school:
Field of study:
Year Graduated:
4-Year College Degree? Yes No Name of school:
Field of study:
Year Graduated:
Graduate Degree? Yes No Name of school:
Field of study:
Year Graduated:
Other Specialty Training and/or Certifications:
EMPLOYMENT HISTORY - MILITARY:
Are you currently or have you ever served in the military? Yes No
If no, please go to the next section.
Branch
of
Service:
Highest
Rank:
Enlistment
Date:
/ / (Anticipated)
Discharge
Date:
/ /
Type
of
Discharge:
Have you ever received any form of disciplinary action (court martial, article 15, demotions,
violations of uniform code, etc.) while in the military? Yes No
If
yes,
please
explain:
What is the most serious infraction you committed in the military, whether detected or
undetected?
5
EMPLOYMENT HISTORY:
Have you previously submitted an application for employment with this agency? Yes No
If
yes,
list
the
approximate
date(s):
List all law enforcement agencies you have submitted an application with in the past:
1.)
Year submitted:
2.) Year submitted:
3.) Year submitted:
4.) Year submitted:
Current Employer: Hire Date:
(Month) (Year)
Position/Title:
Previous Employers: Start with the most recent. Use reverse side of this sheet if space is not adequate.
a.)
(Employer) Start: (Month) (Year) End: (Month) (Year)
b.)
(Employer) Start: (Month) (Year) End: (Month) (Year)
c.)
(Employer) Start: (Month) (Year) End: (Month) (Year)
d.)
(Employer) Start: (Month) (Year) End: (Month) (Year)
e.)
(Employer) Start: (Month) (Year) End: (Month) (Year)
List any job in which you have been fired, asked to resign or forced to leave:
a.)
b.)
c.)
(Employer) (Reason) (Year Terminated)
(Employer) (Reason) (Year Terminated)
(Employer) (Reason) (Year Terminated)
6
1. List all times you have been disciplined, suspended, reprimanded, etc. by any employer:
a.
b.
c.
d.
e.
2. Are you currently having problems with any co-worker or supervisor? Yes No
3. Have you ever received a poor work performance evaluation at any job? Yes No
4. Have you ever been accused of racial /ethnic bias or sexual harass
ment? Yes No
5. Have you ever received unemployment compensation? Yes No
6. Have you ever received worker’s compensation or unemployment Yes No
compensation that you were not entitled to?
7. Did you ever work and get paid under the table or off the books? Yes No
8. Have you ever consumed alcohol while working? Yes No
9. Have you ever used an illegal drug while working? Yes No
10. Have you ever had sexual contact / relations while at work? Yes No
11. Have you ever falsified your time sheet/card? Yes No
12. How
many
times
in
a
normal
work
month
are
you
late?
13. What
is
the
most
valuable
thing
you
ever
took
from
an
employer?
Many people have taken things from a place where they work which they did not have permission
to take. The items taken may have been cash, merchandise or property. You may have simply
borrowed one of these items and forgotten to return it, given merchandise to another person, or
padded your expense account. Below, list every item that you have ever taken from any employer.
Use the back of this sheet if more space is needed.
Item Taken Approximate Value Month/Year Employer
7
THEFT OF PROPERTY:
In the previous section you documented all thefts from a place of employment. This section is to
include all other thefts of property that you have been involved in from other sources at any
time in your life. This could include, but is not limited to taking cash, shoplifting, switching
price tags, giving /receiving unauthorized discounts, receiving stolen property, etc.
1. Have you ever taken anything from a
purse/wallet?
Yes No
2. Taken an
ythi
ng by force?
Yes No
3. Taken a motor vehicle?
Yes No
4. Taken something from within or off a motor vehicle?
Yes No
5. Received or distributed any items you knew or suspected were stolen?
Yes No
6. What
is
the
most
valuable
item
you
have
ever
taken?
In the space provided below, please list EVERYTHING you have ever taken which you did not
have permission to take. This does not include previously mentioned thefts from employers.
Item Taken Approxim
ate Value Month/Year Property Name/State
(or approx. age)
8
CRIMINAL ACTIVITY:
Check the appropriate answer. EXPLAIN ANY ‘YES’ ANSWERS AT THE END OF THIS SECTION
in the explanation area. Be sure to reference your explanation with the corresponding question number.
1. Unlawfully cause a person’s death / person to be hospitalized?
Yes No
2. Falsely report a fire or other emergency situation?
Yes No
3. Falsely report a crime?
Yes
No
4. Use phony or false identification?
Yes No
5. Use another person’s identity to obtain items?
Yes No
6. Use a credit card or ATM card illegally?
Yes No
7. Issue a check knowing you did not have the funds to cover it?
Yes No
8. Commit a “hate crime” (racial, ethnic or religious motive)?
Yes
No
9. Engage in a physical altercation/fight?
Yes No
10. Use or show a weapon during an altercation?
Yes No
1
1. Make a threatening or obscene communication anonymously
?
Yes No
12. Intentionally damage another’s property by any means?
Yes No
13. Carry any type of unauthorized weapon?
Yes No
14. Carry a weapon illegally?
Yes No
15. Been denied a permit to carry a handgun?
Yes No
16. Manufacture or utilize an explosive or incendiary device?
Yes No
17. Make a phony or inflated insurance claim?
Yes
No
18. Knowingly make a false statement on any official document?
Yes No
19. Knowingly make a false statement in a judicial proceeding?
Yes No
20. Take something from someone by force?
Yes No
2
1. Use someone else’s checks or credit cards without their perm
ission?
Yes No
22. Break into a motor vehicle?
Yes
No
23. Break into a building (home / business / etc.)?
Yes
No
24. Set fire to anything?
Yes No
25. Kidnap someone or otherwise keep someone against his or her will?
Yes No
2
6. Have sexual contact with someone without their consent, (using fo
rce
or when they were impaired or otherwise not mentally competent)?
Yes
No
27
. Force som
eone to have sexual relations/contact with you?
Yes No
28. Have sexual relations/contact with a family member other than
your spouse?
Yes
No
29. Have sexual relations/contact with an animal? Yes No
9
30. Been sexually aroused by a fire?
Yes No
31. Paid for sex or been paid for sex?
Yes No
32. Expose yourself in public?
Yes No
33. Been married to more than one person at a time?
Yes
No
34. Possess, sell, produce or distribute any child pornographic material?
Yes No
35. View/download child pornography?
Yes
No
36. Physically or sexually abuse a child?
Yes No
37. Been involved in any illegal sexual activity?
Yes
No
38. Harass or stalk someone?
Yes
No
39. Counterfeit anything?
Yes No
40. Commit blackmail / any form of extortion?
Yes No
41. Forgery?
Yes
No
42. Bribery?
Yes No
4
3.
Ta
mper with a witness or ev
idence?
Yes No
44. Fail to appear in court?
Yes
No
45. Use a computer to commit a crime?
Yes
No
46. Deliberately hurt an animal (other than legally hunting/fishing)?
Yes No
47. Make an illegal bet / Take an illegal bet?
Yes No
4
8.
Im
personate a police
officer?
Yes No
49. Run or evade a police officer?
Yes No
50. Use physical force with your spouse or significant other? (striking,
pushing, slapping, shaking, etc.)
Yes No
5
1.
Use physical force with a parent? (striking, pushing, slapping, etc.)
Yes No
52. Use physical force with your child or anyone else’s.
Yes No
53. Been the subject of a restraining order or a protective order?
Yes No
54. Use a weapon against someone?
Yes
No
55
. Been involve
d in a police investigation as a suspect or witness?
Yes No
56. Convicted of a criminal offense?
Yes No
57. Had a criminal charge reduced in court?
Yes No
58. Had a criminal charge expunged or sealed?
Yes No
5
9. Have the police ever been contacted because of something you did
or
assist
ed someone in doing?
Yes
No
6
0.
Been involved in organized crime? Yes No
10
61. Been involved in any group (gang, KKK, militia, etc.) that advocated Yes No
violence, racial prejudice, terrorist or subversive activity?
Involved means
being a member, associate member, volunteering for, being associated with,
attending meetings, providing financial support or any other type of assistance.
62. What is the most serious criminal act you ever committed, whether detected or undetected?
(Use the back of this page if more space is needed.)
EXPLANATION AREA:
In the space provided, explain any ‘yes’ answer that you have given to the previous questions.
Give date of incident and describe circumstances.
(Use the back of this page if space is not adequate):
11
ILLEGAL DRUGS:
In the chart below, write the dates of your first and last use for each illegal drug. The dates
should be as exact as possible. Remember, lying is an intentional act, not an honest error.
When asked to
give the maximum number of times used for an illegal drug, you must give the
ABSOLUTE MAXIMUM number of times. If you are not sure how many times you used an
illegal drug, then state the MAXIMUM number of times you COULD have used.
In the “How drug used” column, write if the drug was injected, s
norted, smoked, ingested,
etc. If
you have never used one of the listed illegal drugs, put a checkmark in the “
NEVER” column.
DRUG USED FIRST TIME USED LAST TIME USED MAXIMUM TIMES USED HOW DRUG USED NEVER
Marijuana
Hashish
PCP
Angel Dust
THC
LSD
/
Acid
Pe
y
ote
Mescaline
Heroin
Cocaine
Quaaludes
Downers
Tranquilizers
Amphetamine
Steroids
Ecstas
y
/XTC
Preludin
Dilaudid
Talwin
/
PBZ
Speed
Inhalants
Meth-
amphetamine
Psiloc
y
bin
(Mushrooms)
Others:
(Please list type)
12
ILLEGAL DRUGS CONTINUED:
Check the appropriate answer. EXPLAIN ANY ‘YES’ ANSWERS AT THE END OF THIS SECTION
in the explanation area. Be sure to reference your explanation with the corresponding question number.
1. Have you used any other illegal substance that has not been mentioned? Yes No
2. Ever used another person’s prescription medication for recreational purposes? Yes
No
3. Ever misuse or abuse your own prescription medication? Yes No
4. Ever give or sell your own prescription medication? Yes No
5. Have you ever purchased any illegal drug? Yes No
6. Have you ever sold any illegal drug? Yes No
7. Have you ever manufactured, grown, or harvested an illegal drug? Yes No
8. Ever delivered / distributed an illegal drug? Yes No
9. Held or stored any illegal drug for someone else? Yes No
10. Operated a motor vehicle while under the influence of an illegal drug? Yes No
11. Have you been present when anyone: Yes No
Used illegal
drugs
Sold
illegal drugs
Cooked
illegal drugs
Packaged illegal drugs
Transported illegal drugs
12. When is the last time you’ve been in the presence of an illegal drug? (Do not include
circumstances while serving in a sworn law enforcement / official capacity.)
_/ _/
EXPLANATION AREA:
13
ALCOHOL USE:
Check the appropriate answer. EXPLAIN ANY ‘YES’ ANSWERS AT THE END OF THIS SECTION
in the explanation area. Be sure to reference your explanation with the corresponding question number.
1. Have you ever missed work because of alcohol consumption? Yes No
2. Been treated, counseled, or sought help for a drinking problem? Yes No
3. Has drinking ever caused a problem in your personal life or on the job? Yes No
4. Have
you ever been told by someone that they felt you had a drinking problem? Yes No
5. Have
you
ever
purchased
alcohol
for
a
minor?
If yes, how many times? Yes No
6. Have you ever been arrested for an alcohol related crime? Yes No
7. What
is
your
average
consumption
of
alcohol
during
a
typical
week?
8. How
many
times
have
you
been
intoxicated
in
public
in
the
last
2
years?
When
was
the
last
time?
Date:
/
_/_
9. How
many
times
have
you
operated
a
vehicle
while
intoxicated
in
the
past
2
years?
When
was
the
last
time?
Date:
/
_/_
EXPLANATION AREA:
14
TRAFFIC VIOLATIONS:
Check the appropriate answer. EXPLAIN ANY ‘YES’ ANSWERS AT THE END OF THIS SECTION
in the explanation area. Be sure to reference your explanation with the corresponding question number.
1. Have you ever been refused a driver’s license? Yes No
2. Have you ever altered a license or given false information to obtain a license? Yes No
3. Have you ever had driver’s licenses from more than one state at the same time? Yes No
4. Have you ever had your license suspended or revoked? Yes No
5. Did you ever knowingly drive an unregistered motor vehicle? Yes No
6. Did you ever knowingly drive an uninsured motor vehicle? Yes No
7. Did you ever damage another’s property with a vehicle and not report it? Yes No
8. Have you ever fled the scene of an accident? Yes No
9. Do you currently owe any fines for traffic or parking violations? Yes No
10. Ever had a traffic or parking ticket “fixed”? Yes No
11. How
many
traffic
citations
have
you
received
in
your
entire
driving
history?
12. List all traffic citations
(tickets) received for moving violations in the past 5 years:
(Use the back of this page if more space is needed)
VIOLATION MO. / YR. STATE DISPOSITION
State in which you currently possess a driver’s license Driver’s license number
EXPLANATION AREA:
15
PRIOR LAW ENFORCEMENT SERVICE:
Fill out the below section ONLY if you have had SWORN, prior law enforcement service.
Please check the appropriate answer. Explain any ‘yes’ answers on the back of this page. Be sure to
reference your explanation with the corresponding question number. Use additional paper if needed.
While employed as a sworn law enforcement officer, did you ever engage in any of the following:
1. Take something that did not belong to you while
on duty? Yes No
2. Keep anything that you or anyone else had removed from any:
Any bu
ilding/residence Prisoner Crime scene
Yes No
Citizen Acciden
t
scene Evidence room
Vehicle(s) including patrol units
3. Drink alcohol while on duty? Yes No
4. Have sexual relations while on duty? Yes No
5. Sleep on duty? Yes No
6. Commit any felony or misdemeanor while on duty? Yes No
7. Hit or strike a handcuffed person? Yes No
8. Use excessive force? Yes No
9. Use a controlled or illegal substance while on duty? Yes No
10. Smuggle contraband or unauthorized material? Yes No
11. Accept anything in exchange for performing or not performing your duties? Yes
No
12. Remove, copy, or read a file or document when not authorized to do so? Yes No
13. Make a false report or alter a document? Yes No
14. Plant evidence or otherwise “frame” someone? Yes No
15. Lie in court, on a report, or on an affidavit? Yes No
16. Use your official capacity to extort or attempt to extort anyone? Yes No
17. Destroy property / evidence / contraband without booking it? Yes No
18. Been terminated or asked to resign as peace officer? Yes No
19. Been given the option to resign in lieu of termination? Yes No
19. Received
a
written
reprimand?
If
yes,
how
many
times?
20. Received
a
suspension?
If
yes,
how
many
times?
Yes No
Yes No
21. Been formally investigated for misconduct? Yes No
22. Received any other type of disciplinary action? Yes No
23. Lied to anyone during an internal investigation? Yes No
24. How
many
excessive
use
of
force
of
complaints
have
you
received?
25. How
many
citizen’s
complaints
have
you
received?
16
OTHER / CONCERNS:
1. Is there anything in your history that you know our agency would want to know about,
but has not been addressed in this questionnaire or anywhere else in the application
process?
YES
NO
If
yes,
please
explain:
2. Are there any questions or concerns you would like for your examiner to address with you
pri
or to the administration of your polygraph exam
ination?
YES
NO
If
yes,
please
explain:
VERIFICATION OF TRUTHFULNESS:
All of the information I have revealed in this booklet is true, correct and
complete. I have not
intentionally withheld, falsified, or misrepresented
any information in this booklet. By signing below, I give my word that I
have been 100% truthful.
_/ /_
Applicant’s
Signature Date
