Deployment Screening

Deployment Screening

CONFIDENTIAL
Instructions: Please complete the questionnaire below. All questions require a response. Put N/A if the question does not apply to you. The form is not complete until it is signed, dated, and submitted.

We respect your privacy. Your personal information will be kept private, not shared with outside entities, and will only be used for pre-employment purposes. Please view our privacy policy for more information.
My Assignment:*

V1 - Dr. Susan
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Age*
Sex*
Personal Email*
example@example.com
Business/Work Email*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Questionnaire Completion:*

MonthDayYear
Date

HISTORY

All questions require a response. Put N/A if the question does not apply to you.
How did you learn of the company to which you are applying?*
Have you ever applied to this company before? If yes, please explain.*
What is your understanding of this position?*
Please list your reasons/motivation for desiring to working in this position.*
Please list your experience in similar working environments.*
Please list your work experience with this company.*

EDUCATIONAL HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Where did you go to high school (city, state)?*
Where did you go to college (city, state)? Please list diplomas, degree(s).*
Please describe any disciplinary actions taken against you while you were a high school and/or college student.*
In what language are you fluent? How did you learn each language?*

EMPLOYMENT HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Please give a history of your employment in the last 10 years. Please list employer, location, dates of employment, position, job duties, and reason(s) for departure.*
Please list awards or honors granted during your employment.*
Please list and explain reprimands (e.g., verbal, written, suspension). Please specify dates.*
Please list the circumstances of any employment terminations or employer requested resignations (e.g., if you were asked to resign or if you were forced to resign.) Please specify dates.*
What was your greatest challenge in jobs with similar contexts to the job to which you are applying? *
Please list your short-term and long-term professional goals.*

LAW ENFORCEMENT HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Please list your law enforcement experience, departments worked for, and dates of service.*
Please list your rank as a law enforcement officer.*
Please list your specialities as a law enforcement officer.*
Please list any disciplinary actions taken against you (e.g., written/verbal reprimand, suspension). Please specify circumstances.*
Please list any complaints of excessive force filed against you. Please explain the circumstances.*
Please list any honors given to you as a law enforcement officer.*
Have you fired your weapon in the line of duty? Please describe, in detail, the circumstances. Please specify dates. *
Please list your reasons for leaving your law enforcement agency(ies).*

MILITARY HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Have you ever served in the U.S. Military?*
Are you currently in Reserve status for any military branch (e.g., Inactive Ready Reserve [IRR], Inactive National Guard [ING])?*
Please list your dates of service in the military.*
Please list your military branch.*
Please list your military rank.*
Please list your specialities while serving in the military.*
Please list any violations of UCMJ (Uniform Code of Military Justice) (e.g., written/verbal reprimand, Captain's Mast, Courts Marshal, Article 15, Nonjudicial Punishment [NJP], Page 11).*
Please list any honors given to you while in the military.*
Do you have combat experience? If yes, please specify unclassified information only. Where? Dates? Circumstances?*
Please list your rank at discharge.*
Please list your military discharge status (e.g., Honorable, Other Than Honorable, General Under Honorable, Dishonorable).*
Please list your reason for leaving the military.*

SECURITY CLEARANCE HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Please list any security clearances you currently hold. Please specify agency, level, and dates.*
Please list any security clearance you have held in the past. Please specify agency, level, and dates.*
Have you ever been downgraded from a security clearance or had a security clearance revoked? If yes, please specify.*

PERSONAL HISTORY

All questions require a response. Put N/A if the question does not apply to you.
How long have you lived at your current address?*
What is your current relationship status (e.g., single, dating, married, divorced, separated)?*

SingleDatingMarriedDivorcedSeparated
Please list the dates of marriages, divorces, and separations. Put N/A if the question does not apply to you.
Date Married:*
Date Separated:*
Date Divorced:*
Number and ages of children from this relationship:*
Date Married:*
Date Separated:*
Date Divorced:*
Number and ages of children from this relationship:*
Date Married:*
Date Separated:*
Date Divorced:*
Number and ages of children from this relationship:*
Please list the circumstances in which you have sued or been sued by an individual or a company. Please specify dates.*
What is your greatest success/achievement?*
What is your biggest disappointment/failure?*
What are you greatest strengths? Limitations?*
What would other people say are your greatest strengths? Limitations?*
As an adult, how many non-duty physical fights have you been in? Please specify the date(s) and circumstances.*
What are your hobbies? Favorite leisure time activities?*
What is your exercise routine?*
Please describe and explain your tattoos.*
Do you have any pending court cases? Please explain.*

TRAFFIC VIOLATIONS HISTORY

All questions require a response. Put N/A if the question does not apply to you.
How many moving traffic violations have you had in the last five (5) years? Please specify details and dates of infraction(s).*
Do you drive or have you ever driven without insurance? If yes, please explain.*
Have you ever had your license suspended or revoked? If yes, please explain.*
ARREST HISTORY
Please list and describe your felony and/or misdemeanor arrests and/or convictions.*
FIREARMS HISTORY
Have you ever had an accidental discharge (AD) or negligent discharge (NG) with a firearm? Please explain.*

MEDICAL HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Please describe your medical history. Include injury, illness, accident, surgery, aches, and pains. Include prescribed medications, dates, and treatment outcome.*
Have you ever had a head injury or lost consciousness? Please explain.*
Have you ever been diagnosed with concussion? How many? What age? What were the circumstances? Please explain.*
Have you ever been diagnosed with Traumatic Brain Injury (TBI)? Please explain.*
Do you have any concerns about passing the Physical Agility test? Please explain.*
Describe your current medical health.*
Are you currently under a Doctor’s care or being treated for any medical conditions?*
Please list any prescribed medications/drugs you have taken within the last 12 months. For what purpose? What dates? Are you still taking the medication? Please explain.*
What prescribed medications/drugs are you currently taking? For what reason?*
Please list the medications/drugs requiring a prescription that you are currently taking without a prescription.*
Please list the over the counter (OTC) medications you are currently taking.*
Please list the dietary supplements you are currently taking.*
Please list the illegal drugs you have used in the last 12 months.*

MENTAL HEALTH HISTORY

All questions require a response. Put N/A if the question does not apply to you.
Please describe your psychological history as a child, adolescent, and adult. Please specify diagnosis, medications prescribed, length of treatment, and treatment outcome.*
Have you ever been in counseling or therapy? If yes, please select which one(s) below and explain. If no, please select "None of the above" and put N/A.*

Individual CounselingGroup CounselingFamily CounselingMarital CounselingNone of the above
Please explain.*
Please list any medications you are currently taking, or have taken in the last 12 months, for treatment of psychological, emotional, and personality issues.*
What is the most stressful event you have experienced in the last six months? How did you handle it?*
What are your current major stressors?*
What do you do to cope with stress?*
What do you do to cope with remorse?*
How do you handle differences of opinion/conflict (e.g., interpersonal, work-related)?*
How do you show/demonstrate anger/frustration? *
What do you do to cope/deal with anger/frustration in the moment of anger/frustration?*
Have you ever been treated for anger issues or been referred for anger management classes?*

MENTAL HEALTH HISTORY (Continued)

All questions require a response. Put N/A if the question does not apply to you.
When you are feeling low/down in the dumps, what do you do?*
Have you ever had time of more than two weeks when you felt depressed?*
Do you have now, or have you ever been diagnosed with, or had treatment for:*

DepressionAnxietyAttention-Deficit Hyperactivity Disorder (ADHD)Sleep Disorder (e.g., sleep apnea)Sleep-related difficultiesAdjustment DisorderOther psychological, emotional, or personality problems?None of the aboveOther
Please explain.*
Have you ever been prescribed medication for a psychological, emotional, or personality problem?*
Have you ever been hospitalized for a psychological, emotional, or personality problem? *
Have you ever been in any drug and/or alcohol treatment?*
Have you ever had any suicidal thoughts or suicide attempts?*
Have you ever had any homicidal thoughts?*
Please list prior psychological evaluations you have received for work or for any other reason.*

ALCOHOL HISTORY

All questions require a response. Put N/A if the question does not apply to you.
On average, how many nights per week do you drink alcohol? On average, how many alcoholic beverages do you consume per occasion? *
When did you have your most recent alcoholic beverage? What did you have? How many? Where were you? Did you drive?*
What is the most you have drunk on any one occasion in the last two years? How many times have you had this amount per occasion in the last two years?*
How many alcoholic beverages does it take until you feel intoxicated? How often do you have this many or more alcoholic beverages (per week, per month, per year)?*
How do you act/appear when you are drunk? What do others tell you about your actions/appearance when you are drunk?*
What is the worst thing that has happened to you and/or others as a result of your consumption of alcoholic beverages?*
Has anyone ever mentioned a concern about your alcohol drinking?*
Have you ever had a time, in the last five years, when you could not remember something you have said or done while drinking alcohol?*
Have you ever gone to work hung over in the last five years? *
Have you ever gone to work still drunk in the last five years? *
Have you ever been absent from work in the last five years because you had been drinking alcohol?*
When is the last time you consumed alcoholic beverages and then drove? Provide specific information.*
Please list all alcohol related infractions in which you were given a citation, held, or arrested (e.g., Driving Under the Influence (DUI)/Operating Under the Influence (OUI); DWAI (Driving While Ability Impaired); Minor in Consumption/Minor in Possession (MIC/MIP) of Alcohol? Please explain.*

TRAUMA HISTORY

All questions require a response. Put N/A if the question does not apply to you.
What personal and/or work-related traumatic events have you experienced?*
How do you cope with traumatic events? What helps you? Did you seek counseling or any psychological treatment?*
Do you have now, or have you ever been diagnosed with, or had treatment for, Post Traumatic Stress Disorder (PTSD)?*

SIGNATURE
I attest that what I have written/endorsed on this Pre-Deployment Screening is true.
Print Name*
Full Name
Signature*

Clear
Signature
Date*

MonthDayYear
Date
Should be Empty:

Deployment Screening

HISTORY

EDUCATIONAL HISTORY

EMPLOYMENT HISTORY

LAW ENFORCEMENT HISTORY

MILITARY HISTORY

SECURITY CLEARANCE HISTORY

PERSONAL HISTORY

TRAFFIC VIOLATIONS HISTORY

ARREST HISTORY

FIREARMS HISTORY

MEDICAL HISTORY

MENTAL HEALTH HISTORY

MENTAL HEALTH HISTORY (Continued)

ALCOHOL HISTORY

TRAUMA HISTORY

SIGNATURE