Post-Offer Disclosure and Supplemental Agreement

Are you currently a Washington State Dept of Corrections employee?*

Name*

First NameLast Name

Last 4 SSN:*

Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Email:*

example@example.com

Agency applying to:*

If you're applying to either the Washington State Department of Corrections or the Alaska Department of Corrections, please select the facility name you're applying to below. If you're not applying to either agency, please select N/A. *

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:*

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 your name into 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 thirdparty verification will not in any way affect the enforceability of your E-Signature.*

E-signature

Date*

Date

Explanation of the process: Pre-employment screening procedures for police and other public safety positions (firefighter, dispatcher, etc.) include psychological screening. The psychological screening process includes written testing, a review of behavioral history, and an interview by a licensed psychologist. We will conduct the interview via a HIPAA compliant and private video-conference with one of our staff psychologists.

I understand that the psychological screening process typically involves a face-to-face interview with a licensed psychologist. I understand that I will be interviewed via videoconference. I understand and agree that the results of this interview will be used to formulate a decision about my suitability for the job that I have applied for. 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*

Date

I understand that I will not receive a copy of the finalized report*, nor will the status of the report or the results be shared with me. *

E-signature *except where required by law.

I give permission to PSPS to record my activity during the test session and/or psychological interview, including all keystrokes, computer screen activity, and browser history.*

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 and the interview. I understand that compliance with this requirement is mandatory and agree to adhere to it fully.*

E-signature

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

Name*

First NameLast Name

Last 4 SSN:*

This psychological suitability assessment is only one part of the selection process for the position you have applied for. The agency that referred you for assessment has given you an offer of employment conditioned, in part, on the satisfactory completion of a job-related psychological assessment. Your prospective employer may consider the psychologist’s recommendation and the data you provide during this evaluation together with other information such as the background or a polygraph, if administered, to determine whether you meet the suitability standards of the agency.

This Evaluation Assesses Job Relevant Traits And Attributes, And Emotional Stability.

This psychological assessment will consist of standardized written psychological tests, in-depth personal history questionnaires, an examination of any collateral or third-party information made available by the hiring agency (or in the case of medical records, by an authorization from you), as well as an interview with a licensed psychologist with experience screening public safety officers. Note that collateral or third-party information reviewed by the psychologist may include reports from the background investigation (or polygraph examination if administered), you authorized the hiring agency to conduct, and any prior psychological evaluations or records of psychological treatment you have authorized us to obtain and review for the purpose of the current assessment.

One objective of this psychological evaluation is to assess personality traits and attributes. The psychological tests, personal history questionnaires and psychological interview will probe public and private aspects of your life. These inquiries are necessary to adequately assess whether you satisfy the suitability requirements of the position you have been conditionally offered.

A second objective of this assessment is to rule out the presence of job relevant psychopathology (although it is not designed or intended to diagnose mental disorders). Please note that some of the questions will be medical in nature such as past or present psychological/psychiatric treatment. This employment assessment represents the psychologist’s professional opinion about your suitability for the position you have applied for, at the specific agency you have applied to. It is not a statement about your suitability for this same job class with different departments or for a different employment position with the same agency.

If at any time you wish to ask about the relevance of any questions in this process, please let the psychologist know and she/he will explain why the requested information is needed.

Remember, as with any job application, you have the right to terminate the process at any time.

Limits Of Confidentiality And Report Of Findings And Conclusions.

Although your prospective employer is the client of this firm and the interviewing psychologist, and you are not, the psychologist is aware of the duty to conduct this evaluation with fairness, impartiality, and objectivity. Because the psychologist is conducting this evaluation at the request of your prospective employer and for reasons having nothing to do with treatment or health care, you do not have doctor-patient or psychotherapist/patient privilege in your communications with the psychologist. The hiring agency may require a report of pertinent findings about your behavioral history, psychological attributes, and will require a recommendation concerning your suitability for this position following the completion of the assessment. Reports to your prospective employer necessarily will contain private information, but we will make a good faith effort to restrict the disclosure of private information to the minimum necessary to satisfy the purpose of the examination and to support our findings, conclusions, and recommendations. If our findings, conclusions, opinions, or recommendations are challenged in an adjudicative forum, we may make full disclosure of all information as may be necessary or required by law.

Note that if you are hired and at some later date become the subject of a mandated fitness for duty evaluation, worker’s compensation evaluation or other medical evaluation, upon written request from our client (the agency) we will provide the data from this application assessment to a qualified professional. Additionally, if at a later date you apply to this agency again, or to some other public safety employer who is our client, we will request that you authorize us to use the current application information or any archival information contained in earlier assessments of you by our firm for the purpose of verifying the consistency of your self-reported personal history and comparing changes in your testing over time.

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

The hiring agency will maintain any written report provided to it by me in a confidential medical file separate from other personnel information and that the information should be made available only to persons who have a bona fide need to know the information included in the report. Nevertheless, by signing the authorization attached hereto as Exhibit A and authorizing the release of this information to the hiring agency, there is the possibility that the hiring agency could redisclose this information. By signing the authorization you will expressly release me from any liability for the disclosure.

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 have read, understand, and agree to these conditions.*

E-signature

Date*

Date

Have you ever taken any psychological tests or been psychologically evaluated as part of the application process for a police or other public safety position?*

Note: the information you provide may be compared to data from your background and/or polygraph report.

If YES, you must list each department you were psychologically evaluated for, the approximate year, and whether or not you were hired, for each agency in the spaces below.

(If more than five, please use the extra space on the last page to continue.)*

Rows	Department Name	Year	Hired? (Yes/No)
1
2
3
4
5

I understand and agree to participate in this psychological evaluation 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 as counseling nor is it to obtain information for my use. I further understand that since the employing entity is the client of Public Safety Psychological Services, P.L.L.C., all data and the report resulting from this evaluation belongs to the agency. 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.*

E-signature

Date*

Date

In consideration of professional services rendered, I hereby release Public Safety Psychological Services, PLLC, and its agents and all persons 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 (the agency), or in response to a legal requirement, or as part of a fitness-for-duty evaluation, or are used in another agency’s selection process for which I have signed a waiver permitting such use if a waiver is legally required.

E-signature

Date*

Date

I understand that some or all of the information and test data I provide may be used for purposes of psychological research concerning recruitment, selection, and long-term performance of police and public safety officers. All information used for research purposes will be kept anonymous. However, this anonymity does not extend to any admissions covered by state mandated reporting laws. Portions of your data may be made anonymous, and this deidentified data may be shared with researchers. In addition, summary analyses of your deidentified responses may be reported in scientific publications.*

E-signature

Date*

Date

I hereby authorize Public Safety Psychological Services, PLLC to utilize any, and all, information available about me contained in any prior psychological evaluation(s) or treatment report(s) as a part of this current assessment. This release to utilize prior psychological information during the current assessment is valid for one year from today’s date.*

Date*

Date

Under the terms of Title II of the Genetic Information NonDiscrimination Act of 2008 (GINA), family medical history or other genetic information about you will not be requested in the course of this examination and should not be provided by you. “Family medical history” means information about the manifestation of disease or disorder in your family members including your children, siblings, and parents (first degree) and extend to great-great grandparents and first cousins once removed (the children of a first cousin), as well as family members who are in between you and these persons (half-cousins, nieces, nephews, grandparents, great-grandparents, aunts, uncles, great-aunts, and uncles and first cousins".

If in the course of your evaluation you believe you have been dealt with in an unethical or unprofessional manner, you may report your concerns to the Washington State Department of Health (DOH) Health Professions QualityAssurance at (360) 236-4700 or the APA Ethics Office at (202) 336-5930.

I authorize Public Safety Psychological Services,PLLC PC (PSPS) and the psychologist who interview me to use and disclose findings and opinions concerning my past, present or future physical or mental health or condition, as well as conclusions, opinions and recommendations as to my psychological qualification and suitability for the position I have applied for, to the agency that referred me for this examination (hereinafter referred to as the “hiring agency”. This authorization does not authorize any of my prior or current health care providers to disclose personal health care records to PSPS or my prospective employer without separate and specific written authorization, except as permitted by law.

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information may be disclosed if I place my initials in the applicable space next to the type of information.

Mental health information - You must sign below in order for the examination to be conducted.*

E-signature

Drug/Alcohol diagnosis, treatment, or referral information - You must sign below in order for the examination to be conducted. *

I understand that PSPS will make a good faith effort to restrict the disclosure of private information to the minimum necessary to satisfy the purpose of the examination and to support the interviewing psychologist’s findings, conclusions and recommendations. Consistent with the provisions of state and federal law, I understand that the hiring agency will be advised to maintain any written report provided to it by PSPS in a confidential medical file separate from other personnel information and that the information should be made available only to persons who have a bona fide need to know the information included in the report. I have been informed that I will not receive a copy of the written report (except where required by law), nor will I be able to authorize its release to any other person or party.

I expressly acknowledge that PSPS has no control over how the hiring agency uses the report once it receives it. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected under federal law. I expressly release PSPS and the psychologist who interviewed me from any liability for that re-disclosure. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information.

SIGNATURE

You do not need to sign this authorization. However, your refusal will mean that the required psychological evaluation will not take place. Failure to complete the required psychological evaluation may very well have implications for your candidacy for employment, but this is a determination that will be made by the hiring agency.

You may revoke this authorization in writing any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure already made with your permission cannot be undone.

To revoke this authorization, please send a written notice, stating that you are revoking this authorization, to PSPS 20818 44th Ave W Suite 150, Lynnwood, WA 98036.

I have read this authorization and I understand it. Unless revoked, this authorization expires one year from the date below.*

E-signature

Date*

Date

Name*

First NameLast Name

Last 4 SSN:*

Please remember that the information you provide will be verified through background investigation and, in most agencies, a polygraph examination.

Providing false information during the application process may be grounds for rejection during the selection process, or termination from employment if falsification is discovered later.

List ALL employers for the last 10 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 4 jobs in 10 years, or need to provide additional information, use the extra space provided on the last page to provide that information.

Are you currently employed?:*

Current employer's name:*

Most recent employer's name:*

Position:*

Start date:*

End date:*

Reason for leaving:*

Do you have any other employment within the last 10 years to report?

Employer 2:*

Name of Employer:*

Position:*

Start date:*

End date:*

Reason for leaving:*

Do you have any other employment within the last 10 years to report?

Employer 3:*

Name of Employer:*

Position:*

Start date:*

End date:*

Reason for leaving:*

Do you have any other employment within the last 10 years to report?

Employer 4:*

Name of Employer:*

Position:*

Start date:*

End date:*

Reason for leaving:*

If you have additional employment to report, please use the extra space provided at the end of the form.

SOURCE OF CURRENT INCOME: Report ALL income sources including salary, cash payments and any benefits/compensation from any source (such as VA disability payments, worker’s compensation, insurance settlements, trust funds, etc.)

Income Source 1:*

Do you have an additional source of income?:*

Income source 2:*

Do you have an additional source of income?:*

Income source 3:*

Do you have an additional source of income?:*

Income source 4:*

Have you ever been fired or forced to resign from a job? If you have more than two instances to report, please use the blank space on the last page of this document.*

Employer name:*

Date of termination:*

Start Date:*

Length of employment:*

Reason for termination:

Any other terminations/forced resignations to report?*

Employer name:*

Date of termination:*

Start Date:*

Length of employment:*

Reason for termination:

Have you EVER used or experimented with ANY illegal, or controlled drugs, without a prescription?*

If you answered YES to the questions above, please provide the details below. *

Rows	Year First Used	Year Last Used	Total Times Used	Never Used
Prescription medications (Prescribed to you or not)
Cocaine/ Crack Cocaine
Methamphetamine, Crank
Other Stimulants, amphetamine, Dexedrine
Ecstasy
Designer drugs: e.g. Ice, MDMA etc.
Hallucinogens, LSD, Mushrooms
PCP, Crystal, Angel Dust
Opium, Morphine, Heroin
Steroids (Pills/injections)
Tranquilizers (Quaaludes)
Adderall/Ritalin or other prescription medications
Other (please include details on the last page of this document):

Have you EVER used Marijuana? (For ANY reason including medical usage, prescribed or non-prescribed.)*

If yes, please list the year first used:*

Year last used:*

Which state(s) did you use marijuana in:*

Total times used (estimate):*

How many days during the average week do you consume any quantity of alcoholic beverage?

On the days you do consume alcohol, how many drinks do you typically have?*

What is the maximum number of drinks you have consumed in 24 hours during the past year?*

The number of times in the past year you have consumed the maximum amount of drinks reported above.*

The number of drinks you consume before you feel the first effects of alcohol feel “high”, “woozy”, etc.? Count one drink for each 12 oz. can of beer, 4 oz. glass of wine, or 1 oz. shot of liquor.*

The number of drinks you consume before you believe you are intoxicated/drunk, defined as “being able to tell that your thinking and judgement are impaired”? (Count one drink for each 12 oz. can of beer, 4 oz. glass of wine, or 1 oz. shot of liquor).*

The number of occasions you have been intoxicated/drunk (that is, you can tell your thinking and judgement are impaired) during the last 12 months?*

Have you EVER had an arrest expunged, sealed or otherwise removed from your record?*

If you answered YES, to the question above, please indicate how many times you've been arrested. *

Please provide the details requested below for each occurrence. Do not list routine traffic tickets, but do list incidents such as DUIs, DWAIs and reckless driving.

If you were arrested without being convicted or arrested and convicted or pled guilty more than two times, please use the space provided on the last page of this form for additional information.

Have you EVER been arrested? *

Date of arrest:*

Original charges:*

What was the outcome?*

Do you have any other arrests to report?*

Date of arrest:*

Original charges:*

What was the outcome?*

If you have additional arrests to report, please use the extra space provided on the last page.

As a student at a College or University, have you EVER been disciplined for misconduct, suspended, expelled or required to withdraw, for any reason?*

If yes, what year?*

College/University name:*

Reason:*

Disciplinary action you received:*

Have you EVER been named in ANY legal restraining order (By spouse/Romantic Partner, Employer, Neighbor, etc.)?*

If yes, list date(s):*

Provide specific details below:*

Have you EVER been involved in a domestic violence incident (DVI)?*

Provide specific details below:*

Have you EVER been accused of, or committed, "Date Rape", (sexual contact with someone who resisted, whether or not they later complained to authorities)?*

If yes: What year(s)?*

Provide specific details below:*

Have you EVER engaged in sexual acts (including, but not limited to, intercourse, oral sex, masturbation, viewing pornography) while at work? *

If yes, Year(s):*

How many times?*

Have you ever looked at child pornography (girls or boys under age 18) on the internet, or in magazines, movies, or other media?*

If yes, Year(s):*

How often?*

Have you ever had any sexual contact with animals?*

If yes, Year(s):*

How often?*

Have you EVER been rehabilitated or otherwise treated for alcohol related problems? Include in-patient, out-patient, Alcoholics Anonymous (AA), etc. both voluntary and mandated. *

Have you EVER been rehabilitated or otherwise treated for problems with drugs other than alcohol? (Include in-patient, out-patient, 12 step programs, etc. both voluntary and mandated.)*

To conduct an “individualized assessment” required by the ADA, the psychologist must take into consideration your most recent psychological treatment history, as well as all past contact with mental health professionals. You should be aware that a history of psychological treatment is usually not a concern and it does not automatically result in a disqualification.

Have you EVER received services, consultation and/or treatment from a mental health provider, including, but not limited to, a psychologist, psychiatrist, therapist, or family/marriage counselor for ANY reason (Do not include other pre-employment evaluations).*

If YES, how many different Mental Health Professionals have you seen in your life?*

If you were seen by one or more Psychologists or other Mental Health Providers, report the year, number of sessions and reason for each contact in the spaces below. (Use the last page of this form to list additional counseling contacts.)

Year(s):*

Approximate # of sessions:*

Reason you contacted a mental health provider:*

Do you have any other mental health providers to report?*

Year(s):*

Approximate # of sessions:*

Reason you contacted a mental health provider:*

As a civilian (non-military), were you ever evaluated by a psychologist or psychiatrist to determine if a psychological injury or trauma merited a compensation award or disability rating? *

If yes, please provide details:*

Have you served in the military? *

Was your discharge from the service related in any way to psychological issues?

After you were discharged, did you EVER apply to the Veteran's Administration (VA) for a service-connected disability for psychological injuries?*

After you were discharged, did you EVER apply to the Veteran's Administration (VA) for a service-connected disability for medical injuries?*

If you did apply for a service-connected disability, did your Disability Determination Evaluation result in an award?*

If YES, are you currently receiving compensation from the Veteran's Administration for a psychological disability (such as PTSD, Tramautic brain injury TBI etc.)?*

If you were awarded a VA disability, please complete the table below. *

Rows	Nature of Inujury (such as back, neck, tinnitus, PTSD, TBI)	Year award was granted	Percentage Award Granted
For psychological injuries
For medical injuries

As a child or adult, were you EVER evaluated, treated or prescribed medication for Attention Deficit Disorder (ADD), Dyslexia, or other learning disabilities by any mental health or other medical professional(s)?*

If yes, please list date(s):*

Reason(s) for treatment:*

Have you ever been hospitalized for psychiatric or psychological reasons at any time in your life?*

If yes, please list date(s):*

Please list the hospital(s) you were admitted to:*

Have you EVER been required (by the Courts, your Employer, or other reason) to be evaluated and/or treated by a mental health professional for any reason, such as your behavior or alleged behavior?*

If yes, please list date(s):*

Reason(s) for mandated evaluation/treatment:*

Have you EVER engaged in any types of self-mutilation or self-harming behavior, e.g. cutting, burning, etc.?*

Have you EVER been prescribed marijuana, or had a medical marijuana "green card", to help you deal with any medical or psychological condition?*

If yes: What year?:*

Reason for prescription:*

Have you EVER been prescribed medication to help you deal with emotional or psychological symptoms such as depression, anxiety etc.?*

If YES, please indicate any medication(s) you have EVER been prescribed:*

Rows	Yes	No
Anti-depressant or mood elevators such as (procaz, amitriptyline)
Trangquilizers (barbituates, Valium, Librium, Stelazine)
Mood stabilizers (Such as Lithium, Tegretol, etc.)
Sleeping pill (Halcyon, etc.)
Medication to control panic attacks
Medcation to control anxiety
Medication to control obsessive-compulsive behavior
Medication to treat learning disabilities and related problems such as hyperactivity, Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) (Ritalin, Adderall, etc.)
Any other medication to deal with psychological distress

If you answered YES to any of the above, identify the drug(s) and what period(s) of time (year,month) and when it was last used in the spaces provided below. Please use the extra space provided on the last page of this document if you need more room.*

Rows	Name of Medication	Year first used	Year last used	Total times used
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Have you ever been dependent on, or addicted to, any prescription medication?*

Did you take the SAT/ACT?*

If yes, what was your score?*

What is the fastest you have ever driven a motor vehicle in your life? (Do not include as required by a job or on a race track.)*

When and where did you drive that fast?*

Have you ever been involved in a road rage incident either as a victim or perpetrator? (flipping off, chasing or being chased, aggressive honking, yelling out the window, etc.)?*

Date of most recent incident:*

Were the police called?*

If you answered YES above, please describe the circumstances that led to the incident.*

Do you have any tattoos?*

How many do you have?*

Describe each tattoo (e.g. zodiac sign, flower, etc.) and the location on your body.*

Are any of your tattoos visible to other people if you are only wearing shorts and a t-shirt?*

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

E-signature

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.

Please remember that the information you provide will be verified through background investigation and, in most agencies, a polygraph examination. Providing false information during the application process may be grounds for rejection during the selection process, or termination from employment if falsification is discovered later.

I hereby certify that the information provided by me in response to all of the questions in this application process may be grounds for my rejection during the selection process, or termination after employment if falsification is discovered later.

E-signature*

Date*

Date

Please use this section if you need extra space for additional information from the questionnaire.

Post-Offer Disclosure and Supplemental Agreement

Remote Test Administration Agreement

Psychological Interview Conducted By Video-Conference

Informed Consent And Release

Disclosure, Informed Consent And Release Statement For The Job Suitability Assessment After A Conditional Offer Of Employment.

Overview Of The Selection Process After A Conditional Offer Of Employment (COE)

Applicant's Statement Of Understanding And Legal Release

Genetic Information

Exhibit A - Authorization To Use And Disclose Protected Health Information

Supplemental Psychological History Questionnaire For The Job Suitability Assessment After A Conditional Offer Of Employment (COE)

Section 1A: Work History And Income Sources

Section 1B: Work Terminations/Resignations

Section 2A: Substance Use

Section 2B: Alcohol Use

Section 3A: Legal History: Arrests And Outcomes

Section 3B: Legal History: Miscellaneous

Section 4A: Rehabilitation/Treatment History

Section 4B: Psychological Treatment And Evaluation History

Section 4C: Medication

Section 5: Miscellaneous