Recertification Screening

Recertification 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*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position*
Current/Anticipated Team/Detail*
Current/Anticipated Deployment Country*
Current/Anticipated Dates of Deployment*

MonthDayYear
Date
Date of Last Psychological Assessment*

MonthDayYear
Date
Date of Questionnaire Completion*

MonthDayYear
Date

PRIVATE CONTRACTING HISTORY

Please list all companie(s), dates, and specialities. All questions require a response. Put N/A if the question does not apply to you.
Company, Date, Speciality*
Company, Date, Speciality*
Company, Date, Speciality*
MILITARY HISTORY

Please list all dates, specialities, rank, discharge status, and reason for leaving. All questions require a response. Put N/A if the question does not apply to you.
Date, Speciality, Rank, Discharge Status, and Reason For Leaving*
Date, Speciality, Rank, Discharge Status, and Reason For Leaving*
Date, Speciality, Rank, Discharge Status, and Reason For Leaving*
LAW ENFORCEMENT HISTORY

Please list all dates, specialities, rank, and reason for leaving. All questions require a response. Put N/A if the question does not apply to you.
Date, Speciality, Rank, and Reason For Leaving*
Date, Speciality, Rank, and Reason For Leaving*
Date, Speciality, Rank, and Reason For Leaving*

DEPLOYMENT INFORMATION

All questions require a response. Put N/A if the question does not apply to you.
Since your last psychological assessment for deployment, where and when were you deployed?*
Describe your duties at your deployment locations*
How long did it take you to get adjusted to your site(s)? Please describe your experience.*
Describe your most favorable experience(s) on deployment.*
Describe your least favorable experience(s) on deployment.*
While deployed, did you sustain injuries? If so, please describe the injury, the date of the injury, and the injury's current disposition.*
While deployed, did you experience or witness a traumatic event (e.g., explosions, firefights, fire, discharge of weapon, medical emergency)? Please describe your experience.*
While deployed, did you have a head injury or loss of consciousness? Please explain.*
While deployed, were you diagnosed with concussion? What were the circumstances? Please explain.*
While deployed, were you diagnosed with Traumatic Brain Injury (TBI)? Please explain.*

MEDICAL INFORMATION

All questions require a response. Put N/A if the question does not apply to you.
Describe your current medical health.*
Since your last psychological assessment for deployment, have you had a head injuryor loss of consciousness outside of deployment (e.g., motorcycle accident, sports injury?*
Are you currently under a medical 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.*
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 (Continued)

All questions require a response. Put N/A if the question does not apply to you.
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?*
Have you ever been treated for anger issues or been referred for anger management classes?*
When you are feeling low/down in the dumps, what do you do?*
Since your last psychological assessment for deployment, have you had time of more than two weeks when you felt depressed?*
Since your last psychological assessment for deployment, have you been diagnosed with or had treatment for any of the below. If yes, please explain. If no, please select "None of the above" and put N/A.

DepressionAttention-Deficit Hyperactivity Disorder (ADHD)Adjustment DisorderSleep Disorder (e.g., sleep apnea)Sleep-related difficultiesNone of the aboveOther psychological, emotional, or personality problemsOther
Please explain.*
Since your last psychological assessment for deployment, have you been hospitalized for a psychological, emotional, or personality problem?*
Since your last psychological assessment for deployment, have you been in any drug and/or alcohol treatment?*
Since your last psychological assessment for deployment, have you had any suicidal thoughts or suicide attempts?*
Since your last psychological assessment for deployment, have you had any homicidal thoughts?*

ARREST INFORMATION

All questions require a response. Put N/A if the question does not apply to you.
Since your last psychological assessment, have you been arrested for a crime, misdemeanor and/or felony? Please explain.*
ALCOHOL INFORMATION
Since your last psychological assessment for deployment, 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? Please explain.*
How many nights per week do you drink alcohol? On average, how many alcoholic beverages do you consume per occasion?*
When is the last time you consumed alcoholic beverages and then drove a vehicle? Provide specific information.*

SIGNATURE
I attest that what I have written/endorsed on this questionnaire is true.
Print Name*
Full Name
Signature*

Clear
Signature
Date*

MonthDayYear
Date
Should be Empty:

Recertification Screening

PRIVATE CONTRACTING HISTORY

MILITARY HISTORY

LAW ENFORCEMENT HISTORY

DEPLOYMENT INFORMATION

MEDICAL INFORMATION

MENTAL HEALTH HISTORY

MENTAL HEALTH HISTORY (Continued)

ARREST INFORMATION

ALCOHOL INFORMATION

SIGNATURE