• Behavioral Questionnaire

    CONFIDENTIAL

  • Instructions: Please complete the questionnaire below. The form is not complete until it is signed, dated, and submitted.

  • Please answer YES or NO to the following questions. For questions in which you have answered YES, you MUST EXPLAIN. In your explanation, you MUST PROVIDE DETAILED INFORMATION including specific circumstances, dates, and status of situation. 

  • 1. Have you ever failed a background investigation?*
  • 2. Have you ever failed to meet all of your financial obligations?*
  • 3. Have you ever filed for bankruptcy?*
  • 4. Have you ever had a repossession or foreclosure?*
  • 5. Have you ever been delinquent in paying spousal or child support?*
  • 6. Have you ever had a bill turned over to a collection agency for non-payment?*
  • 7. Have there been any “bounced” checks (had them returned for nonsufficient funds) within the past one year on any account on which you are listed?*
  • 8. Has a landlord ever served you with an eviction notice?*
  • 9. Have you ever been involved in an automobile accident involving injuries or property damage that you failed to report to the authorities?*
  • 10. Have you ever had a traffic ticket turn to a warrant for your arrest?*

  • Behavioral Questionnaire

    All questions require a response.
  • 11. Has your driver’s license ever been suspended or revoked?*
  • 12. Have you ever received a ticket for careless or reckless driving?*
  • 13. Have you ever had your car insurance canceled or been placed into the high-risk category (assigned risk)?*
  • 14. Have you ever driven a motor vehicle while impaired by alcohol or illegal drugs?*
  • 15. Have you ever had to appear in criminal court (other than for traffic tickets, as a witness, jury duty, or in the line of duty)?*
  • 16. Have you ever had to appear in juvenile or family court as a criminal defendant for any reason?*
  • 17. Have you ever been named in a restraining order or protective order?*
  • 18. Have you ever been involved in or accused of peeping into people’s windows (voyeurism)?*
  • 19. Have you ever been involved in making obscene phone calls?*
  • 20. Have you ever been involved in or accused of flashing or exposing yourself?*

  • Behavioral Questionnaire

    All questions require a response.
  • 21. As an adult, have you ever been involved in or accused of sexual contact with someone under the age of 18?*
  • 22. Have you ever been involved in or accused of purchasing or selling any item, which you knew or suspected to be stolen?*
  • 23. Have you ever been involved in or accused of taking any cash, goods, products, supplies or merchandise from a place of employment?*
  • 24. Have you ever been aware of a co-worker involved in theft?*
  • 25. Have you ever been involved in or accused of assault or battery?*
  • 26. Have you ever been involved in or accused of arson?*
  • 27. Have you ever been involved in or accused of forgery or falsification of any type of official document?*
  • 28. Have you ever failed to file or been involved in or accused of falsification of income tax returns?*
  • 29. Have you ever been involved in or accused of shoplifting age 16 or older?*

  • Behavioral Questionnaire

    All questions require a response.
  • 30. Have you ever been involved in or accused of burglary age 16 or older?*
  • 31. Have you ever been involved in or accused of theft of cash age 16 or older?*
  • 32. Have you ever been involved in or accused of theft of goods age 16 or older?*
  • 33. Have you ever been involved in or accused of theft of services (e.g., unauthorized cable TV hookup)?*
  • 34. Have you ever been involved in or accused of trespassing?*
  • 35. Have you ever been involved in or accused of violation of a court order??*
  • 36. Have you ever been involved in or accused of domestic violence?*
  • 37. Have you ever been involved in or accused of carrying a concealed weapon without a permit?*
  • 38. Have you ever been involved in or accused of vandalism or malicious mischief?*
  • 39. Have you ever been involved in or accused of illegal drug use?*

  • Please specify date drug was first used, date drug was last used, and the total number of times drug was used. Put N/A if it does not apply to you.

  • Behavioral Questionnaire

    All questions require a response.
  • 40. Have you ever been involved in or accused of wildlife violations (hunting, fishing, poaching)?*
  • 41. Have you ever been involved in or accused of any other undetected crimes not already listed?*
  • 42. Have you ever been fired or forced/asked to resign from a place of employment?*
  • 43. Have you ever failed to complete the probationary period for a job?*
  • 44. Have you ever quit a job without notice?*
  • 45. Have you ever received any reprimands at work?*
  • 46. Have you ever been suspended or demoted or been given a reduction in pay?*
  • 47. Have you ever received unsatisfactory or below average performance evaluations?*
  • 48. Have you ever been re-assigned at work due to disciplinary matters or unsatisfactory performance?*
  • 49. Have you ever had to go through a re-training or remedial training as a result of unsatisfactory or below standard performance in any job?*

  • Behavioral Questionnaire

    All questions require a response.
  • 50. Have you ever been the subject of complaints or disciplinary action for behavior related to any type of harassment?*
  • 51. Have you ever received a performance evaluation or been the recipient of a disciplinary action you felt was unfair?*
  • 52. Have you ever reported to work under the influence of alcohol or illegal drugs?*
  • 53. Have you ever used alcohol or illegal drugs at work in violation of employer’s rules?*
  • 54. Have you ever been disciplined at a job or in the military for use of alcohol or illegal drugs?*
  • 55. Have you ever purchased any illegal drugs?*
  • 56. Have you ever sold or provided any illegal drugs to anyone?*
  • 57. Have you ever been involved in any type of domestic disturbance where the police have been called?*
  • 58. Have you ever hit, slapped, struck, or in any manner injured your current or past spouse or romantic partner?*
  • 59. Have you ever hit, slapped, struck, or in any manner injured a child?*

  • Behavioral Questionnaire

    All questions require a response.
  • 60. Have you ever hit, slapped, struck, or in any manner injured your parents, siblings, grandparents, or any other relative?*
  • 61. Have you been contacted by Child Protective Services (CPS) or any other similar agency because you were the subject of an investigation?*
  • 62. Have you been terminated from a job in public safety?*
  • 63. Have you ever resigned from a job in public safety?*
  • 64. Have you ever held someone against his/her will while not serving in the line of duty?*
  • 65. Have you ever had sex or have you ever been accused of having sex with someone who was non-consenting or incapacitated?*
  • 66. Have you ever bought, sold, traded, or possessed erotic or nude pictures of children (printed or on the computer)?*
  • 67. Have you ever taken erotic or nude pictures of children?*
  • 68. Have you ever been the middleman, go between, or “done a favor for a friend”, by becoming involved in a drug transaction?*
  • 69. Have you ever grown and/or manufactured legal or illegal drugs or narcotics?*

  • Behavioral Questionnaire

    All questions require a response.
  • 70. Do you have any relationships that are involved in the illegal growth or manufacturing of legal or illegal drugs or narcotics?*
  • 71. While in military service, were you ever AWOL or on unauthorized absence?*
  • 72. Have you ever filed a false report involving the law, insurance claims, compensation, etc.*
  • 73. Have you ever tortured or abused an animal or been witness of such acts?*
  • 74. Are you currently, or have you ever been a member of a street gang?*
  • 75. Are you currently, or have you ever been under investigation by law enforcement for alleged violation of the law?*
  • 76. Do you think anyone would give you an unfavorable recommendation?*
  • 77. Have you ever written anything (e.g., articles, opinions, editorials) for publication by request from another party or with the personal desire to publish?*
  • 78. Have you ever been interviewed for print, electronic or digital media?*
  • 79. Have you ever been asked and provided comments for use on or off the record either in a print, electronic or digital format?*

  • Behavioral Questionnaire

    All questions require a response.
  • 80. Have you ever published a website?*
  • 81. Have you ever managed or been involved with another person’s personal or business website(s)?*
  • 82. Do you use social media? Which platforms?*
  • 83. Do you post? Use Twitter? Keep an online journal?*
  • 84. Do you visit child pornographic websites?*
  • 85. Have you ever been charged or convicted of a hate crime?*

  • SCENARIOS

    Please answer the following questions. All questions require a response.

  • SIGNATURE

  • I attest that what I have written/endorsed on this questionnaire is true.

  • Date*
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