Pre-Offer - Phase 1 Disclosure & Supplemental Questionnaire

Pre-Offer - Phase 1 Disclosure & Supplemental Questionnaire

Rev. 06.17.2025
Greetings,

Please complete the following document at least 24 hours prior to your scheduled start time.
Using your smartphone or tablet, please take a photo of your government issued ID (driver's license, passport, ID card etc., please no work or military IDs). Please make sure the image is clear, horizontal, and readable before submitting. If you do not have a smartphone to use, please email a copy of your ID to records@psspc.net.:*
Please select which agency you are testing for below. If your agency is not on the list below, then this form is not for you. If your agency is not on this list, do not add it! Please email records@psspc.net for assistance.*
For Washington State Dept of Corrections candidates, please indicate which facility you're applying to.*
Which Community Corrections office are you applying to?*
You agree that your electronic signature is the legal equivalent of your manual signature on this document. You consent to be legally bound by your electronic signature. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-signature and that the lack of such certification or thirdparty verification will not in any way affect the enforceability of your E-Signature.
I understand that I am filling out the following document as part of one of the above agency’s hiring process. I understand that if I fill this document out for an agency not listed above, that I will be asked to fill out the appropriate documentation before my report can be sent to my agency.*
E-signature
Date*

MonthDayYear
Date

Remote Test Administration Agreement
Your Name*

Last NameFirst Name
Last 4 SSN:*
Agency:*
Position applying for:*
Please select the position you're applying to from the dropdown list. If your position isn't listed, please select "Other" and type the position into the dialogue box. N/A is not an acceptable answer.
Position applying for:*
Email address:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
PSPS is offering remote administration of the psychological test battery to job applicants. This option for testing will not require the usual in-person proctor but will nevertheless be proctored using a video-conference link to ensure that test administration protocol is followed.

The testing presented online is protected by federal copyright law and any dissemination or copying of the material presented will be prosecuted to the full extent of the law. Accessing non test-related materials during the test administration is also expressly prohibited. If any of the above activities are detected, this behavior is grounds for disqualification from the hiring process and/or legal prosecution.

Utilizing remote testing services is expressly conditioned on the applicant’s agreement to the following terms, in addition to those above (Please sign each space below):
You agree that your electronic signature is the legal equivalent of your manual signature on this document. You consent to be legally bound by your electronic signature. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature.
E-signature*
Date*

MonthDayYear
Date
I consent to Public Safety Psychological Services, PLLC and/or Public Safety Selection PC (hereafter "PSPS") to monitor my activities during remote test administration by electronic means.*
E-signature
I give permission to PSPS to record my activity during the test session, including all keystrokes, computer screen activity, and browser history during the test process.*
E-signature
I acknowledge that the copying or distribution of test materials presented during the remote testing session is a violation of federal copyright law and will subject me to legal prosecution.*
E-signature
I acknowledge that the copying or distribution of test materials presented during the remote testing session is grounds for disqualification from the hiring process.*
E-signature
I acknowledge that accessing non-test related materials, or consulting with other persons during the remote testing session is grounds for disqualification from the hiring process.*
E-signature
I acknowledge that I may not take any notes during the tests or during the interview with the doctor (should I have one) and if I do, then it is grounds for disqualification from the hiring process.*
E-signature
I acknowledge that the use of Artificial Intelligence (AI), by any means, including hardware (e.g., smart glasses) or software, during the remote testing session is a violation of our policy and may result in my removal from the hiring process. *
E-signature
I affirm that I will not use any type of artificial intelligence, smart glasses, or other assistive or augmented technologies during any part of the evaluation process, including the written tests. I understand that compliance with this requirement is mandatory and agree to adhere to it fully.*
I acknowledge the above-stated prohibition on using AI applies to all uses including but not limited to: recording, transcribing, or use in drafting, editing, or aiding in any way, my responses to test or interview questions.*
E-signature

Disclosure And Release Form For A Job Suitability Assessment Before A Conditional Offer Of Employment
Last/First name:*
Last 4 SSN:*
Agency:*
Position:*
Have you ever used an alias?*
If yes, please list all aliases used:*
The Selection Process Before A Conditional Offer Of Employment (COE): This suitability assessment will be conducted before you are given a conditional offer of employment and is only one part of the selection process for the position you have applied for. Department representatives will use the data and findings from this pre-COE assessment together with other information such as the pre-COE background investigation or polygraph to select those who appear to be the most qualified applicants up to that point in the selection process, and they may then be given a Conditional Offer of Employment (COE).

Applicants who are extended a COE will be required to complete the remaining post job offer selection steps which usually include: (1) post-COE psychological evaluation; (2) post-COE background investigation; (3) post-COE polygraph; and (4) post-COE medical examination. Non-medical information revealed or discovered at any post-job offer selection stage that is relevant to your suitability for this position will be considered by the agency and could lead to withdrawal of the COE, or your rejection for failure to meet non-medical department standards.

The Purpose Of This Assessment: This suitability assessment which will be conducted before you are given a COE by your prospective employer is intended to assess normal range personality traits and characteristics (including but not limited to: judgement, problem solving, learning, written and oral communications, interpersonal skills, teamwork, acceptance of criticism, following rules and regulations, adaptability, dependability, initiative, self-control, assertiveness, integrity), which have been judged to be essential for successful performance in this position. It is important to note that this pre-COE suitability assessment does not assess an applicant’s “mental health” or look for any symptoms of a mental or psychological disorder or disability, or physical disability. Therefore, at this pre-COE stage you will not be asked any questions regarding: past or present psychological/psychiatric treatment; use of any medication to treat psychological or medical problems; lifetime frequency of illegal drug use/abuse; alcohol use/abuse; or any other questions that directly “lead to” the identification of a disability covered by the Americans with Disabilities Act (ADA). Remember, as with any job application, you have the right to terminate the process at any time.

Confidentiality: The information and recommendation resulting from this assessment will only be shared with your prospective employer for purposes related to your possible employment at the agency you have applied to. However, if you are hired and subsequently become the subject of a fitness for duty evaluation, worker’s compensation evaluation or other medical evaluation, we will provide this application data to a qualified professional upon written request from our client, the agency.

Exceptions to this confidentiality may be required by law which include, but are not limited to child abuse, a threat of serious harm to self or other or by subpoena. Finally, in the event you sign a waiver permitting access to this information as part of your application to another public safety employer, we may release the data to the psychologist contacted by that agency.

Freedom to Decline to Participate: You have the right to decline to participate in this evaluation. However, your refusal to participate may result in your not proceeding further in the selection process.

Applicant’s Statement of Understanding and Legal Release

You agree that your electronic signature is the legal equivalent of your manual signature on this document. You consent to be legally bound by your electronic signature. You further agree that your use of a keypad, mouse, or other device to select an item, button, icon or similar act/action constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature.
I understand and agree to participate in this non-medical pre-job offer suitability assessment of my traits and characteristics as one part of the selection process for this position. I am aware that the purpose of this evaluation is to provide information to the agency about my suitability for working in the position for which I am applying. I understand that this assessment is not intended for benefit or to obtain information for my use. I further understand that since the employing entity is the client of Public Safety Selection PC, all data and the report resulting from this evaluation belongs to the department. Accordingly, in consideration of professional services rendered, I waive any right I may have to know test results, interpretations made, and access to the original data from which final recommendations have been made.*
Date*

MonthDayYear
Date
In consideration of professional services rendered, I hereby release Public Safety Selection, PC, and its agents from all liability or damage claims which may result from their furnishing data, opinions and recommendations, produced for this evaluation during this selection process, or at a future time if the records are required by our client, or in response to a legal requirement, or as part of a fitness-for-duty evaluation, or are used in another selection process for which I have signed a waiver permitting such use.*
Date*

MonthDayYear
Date
I understand that some or all of the information and test data I provide may be used for purposes of research concerning recruitment, selection and long-term performance of police and public safety officers. All information used for research purposes will be kept completely anonymous. However, this anonymity does not extend to any admissions covered by state mandated reporting laws.*
Date*

MonthDayYear
Date
I hereby authorize Public Safety Selection, PC, to utilize any and all prior non-medical test and personal history data, reports or communications regarding any prior evaluations as part of this current assessment. This release to utilize non-medical information from prior applications during the current assessment is valid for one year from today’s date.*
Date*

MonthDayYear
Date
Have you ever applied for a police or other public safety position?*

Supplemental Personal History Questionnaire For A Job Suitability Assessment Prior To A Conditional Offer Of Employment (COE)
Last/First name:*
1A - Work History
List ALL employers in the last ten years (but not different positions for the same employer), including part-time and seasonal positions. Account for ALL time periods including school and unemployment, starting with the present. If you have had more than five (5) jobs in ten (10) years, use an extra piece of paper to provide that information.
Are you currently employed?:*
Name of most recent employer:*
Position:*
Start date:*
Do you have any other jobs to report?*
Name of employer:*
Position:*
Start date:*
End date:*
Reason for leaving:*
Do you have any other jobs to report?*
Name of employer:*
Position:*
Start date:*
End date:*
Reason for leaving:*
Do you have any other jobs to report?*
Name of employer:*
Position:*
Start date:*
End date:*
Reason for leaving:*

1B - Work Terminations/Resignations
Have you ever been fired or forced to resign from a job?*
Employer:*
Start date:*
Date of termination/resignation:*
Length of employment:*
Reason for termination/departure:*
Any other terminations/resignations to report?*
Employer:*
Start date:*
Date of termination/resignation:*
Length of employment:*
Reason for termination/departure:*

Section 3 - Legal History: Arrests and Outcomes
Have you ever had an arrest expunged, sealed or otherwise removed from your record?*
Have you ever been arrested?*
How many times?*
Date of arrest:*
Original charges:*
Outcome*
Any other arrests to report?*
Date of arrest:*
Original charges:*
Outcome*
If you were arrested without being convicted or arrested and convicted or pleaded guilty more than two times, please use the back of this form or a separate sheet of paper for additional information.

Section 3 - Legal History: Miscellaneous
As a student at a College or University, have you ever been disciplined for misconduct, suspended, expelled or required to withdraw, for any reason?*
Year:*
University/College name:*
Reason:*
Disciplinary action:*
Have you ever been named in any legal restraining order (by spouse/romantic partner, employer, neighbor, etc.)?*
Date(s):*
Reason:*
Have you ever been involved in a domestic violence incident?*
If yes, please include details:*
Have you ever committed, or been accused of committing threats of physical harm; stalking; or actual physical harm, toward anyone at any time?*
Date(s):*
If yes, please include details:*
Have you ever been accused of, or committed "Date Rape" (sexual contact with someone who resisted, whether or not they later complained to authorities)?*
Date(s):*
If yes, please include details:*
Have you ever engaged in sex acts (including, but not limited to, intercourse, oral sex, masturbation, viewing pornography) while at work?*
Date(s):*
How many times?*
Any complaints or discipline regarding this behavior?*
Please include details. *
Have you ever looked at child pornography (girls or boys under age 18) on the internet, or in magazines, movies, or other media?*
Date(s):*
How often?*
Have you ever had any sexual contact with animals?*
Date(s):*
How often?*
Have you ever purchased alcohol for a minor?*
If yes: What age were you?*
What age were the minors?*
Do you have any tattoos? *
How many?*
Describe each tattoo and location (e.g. zodiac sign, flower, etc.)*
Are any of your tattoos visible to other people if you are only wearing shorts and a t-shirt?*
Did you take the SAT/ACT?*
If yes, what was your score?*

I attest that I completed this form myself with no assistance from anyone else. *
Applicant Certification

You agree that your electronic signature is the legal equivalent of your manual signature on this document. You consent to be legally bound by your electronic signature. You further agree that your use of a keypad, mouse, or other device to select an item, button, icon or similar act/action constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature.
I hereby certify that the information provided by me in response to the questions above is true and accurate. I am aware that providing false information during the application process may be grounds for my rejection during the selection process, or termination after employment if falsification is later discovered.*
Date*

MonthDayYear
Date

Please use this space to provide additional information from the questionnaire.
Should be Empty:

Rows	Department Name	Year Applied	Hired? (Yes/No)
Department 1
Department 2
Department 3
Department 4
Department 6

Rows	Never Used	Used Once	Used more than once	Date/Year last used
Cocaine
Hallucinogens, LSD, Mushrooms
PCP, Crsytal, Angel Dust
Opium, Morphine, Heroin
Ecstasy, Ice, MDMA, etc.
Methamphetamine (Crank)
Steroid (by injection or pills)

Pre-Offer - Phase 1 Disclosure & Supplemental Questionnaire

Remote Test Administration Agreement

Disclosure And Release Form For A Job Suitability Assessment Before A Conditional Offer Of Employment

Supplemental Personal History Questionnaire For A Job Suitability Assessment Prior To A Conditional Offer Of Employment (COE)

1A - Work History

1B - Work Terminations/Resignations

Section 2: Substance Abuse

Section 3 - Legal History: Arrests and Outcomes

Section 3 - Legal History: Miscellaneous