Da Form 2801 PDF Details

In the elaborate dance of procedures and protocols within the military, few documents carry the precision and gravity of the DA Form 2801, commonly known as the Polygraph Examination Statement of Consent. This form serves as a cornerstone in upholding the ethics and legality of administering polygraph examinations within the United States Army, as directed under AR 195-6 with the PMG as its proponent. It meticulously records the consent of individuals undergoing this scrutiny, ensuring that their rights are not only acknowledged but protected. The form emphasizes the voluntary nature of participation, highlighting that refusal to undergo the examination does not subject individuals to adverse action purely based on their choice. Additionally, it emphasizes the examinee's right to consult with legal counsel, the presence of surveillance measures for transparency, the extent of questioning, and the potential use of examination results in further administrative, military, or judicial actions. With spaces designated for the signatures of the examinee, witnesses, and the examiner, the DA Form 2801 stands as a testament to the commitment of the U.S. Army to conduct its operations within the framework of trust, consent, and legal integrity. This approach underscores the significant weight placed on individual rights, even within the rigorous demands of military protocols, affirming the army's dedication to ethical standards.

QuestionAnswer
Form NameDa Form 2801
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespolygraph report sample, online lie detector test, polygraph consent form template, passed lie detector test results template

Form Preview Example

POLYGRAPH EXAMINATION STATEMENT OF CONSENT

FILE NUMBER

 

For use of this form, see AR 195-6; the proponent is PMG.

 

 

 

LOCATION

TIME

DATE

 

 

 

NAME (Last, First, MI)

GRADE/STATUS

ORGANIZATION OR ADDRESS

STATEMENT OF CONSENT

In the presence of the witness(es) whose signature(s) appear below, my rights, as specified on DA Form 3881 (completed copy

attached), have been explained to me by

 

who informed me that he/she is a

polygraph examiner of the United States Army. I have been advised that this polygraph examination statement of consent is being completed in connection with:

In conjunction with explaining the nature of the polygraph examination, I have been told:

a.that should I refuse to undergo a polygraph examination, no adverse action may be taken against me based solely on my refusal.

b.that I have the right to talk privately with a lawyer before, during and after the polygraph examination.

c.that the examination area is equipped with a two-way mirror or observation device.

d.that the examination will be monitored/recorded.

e.that questioning may occur before, during and after the instrument portion(s) of the polygraph examination.

f.that anything I say or do during the polygraph examination may be used against me in my administrative, military or judicial proceedings.

g.that the polygraph examination will not be conducted without my voluntary consent and even though I am now giving my consent, I can withdraw it at any time and the examination will be stopped.

Understanding my unqualified right to refuse, Ido hereby this date of my own free

will consent to undergo a polygraph examination. I have not been threatened, coerced, unlawfully induced or promised anything in conjunction with my consent to undergo a polygraph examination.

WITNESSES

SIGNATURE

TYPED NAME AND ORGANIZATION/ADDRESS

SIGNATURE

SIGNATURE OF EXAMINEE

SIGNATURE OF EXAMINER

TYPED NAME AND ORGANIZATION OF EXAMINER

TYPED NAME AND ORGANIZATION/ADDRESS

EXHIBIT NUMBER

DA FORM 2801, JUN 2011

PREVIOUS EDITIONS ARE OBSOLETE.

APD LC v1.00

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2. After filling in this section, go to the next part and fill out the necessary particulars in all these blanks - Understanding my unqualified right, do hereby this date of my own free, SIGNATURE, WITNESSES, SIGNATURE OF EXAMINEE, TYPED NAME AND ORGANIZATIONADDRESS, SIGNATURE OF EXAMINER, SIGNATURE, TYPED NAME AND ORGANIZATION OF, TYPED NAME AND ORGANIZATIONADDRESS, EXHIBIT NUMBER, DA FORM JUN, PREVIOUS EDITIONS ARE OBSOLETE, and APD LC v.

Part no. 2 in completing polygraph report sample

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