DA Form 2801 at a glance
What it is: DA Form 2801 is the Polygraph Examination Statement of Consent.
Who signs: The examinee signs on the Signature of Examinee line, the examiner on the Signature of Examiner line, and each witness on a Witnesses Signature line.
A filled-in DA Form 2801 example: a soldier signs before a polygraph examination
How to fill out DA Form 2801, box by box
File Number, Location, Date, Time, Name, Grade/Status and Organization or Address
Enter the File Number, then the Location, Date and Time, the Name (Last, First, MI), the Grade/Status and the Organization or Address.
Your rights explained and the connection of the statement
Enter who has explained to you your rights, as specified on DA Form 3881 (completed copy attached), and who informed you that he/she is a polygraph examiner of the United States Army.
Enter what this polygraph examination statement of consent is being completed in connection with.
Understanding my unqualified right to refuse, I
Enter your name (Last, First, MI) in the blank after "Understanding my unqualified right to refuse, I".
Signature of Examinee, Signature of Examiner and Witnesses
Enter the Typed Name and Organization of Examiner.
Each of the Witnesses enters a Signature and a Typed Name and Organization/Address.
Enter the Exhibit Number.
More rules for DA Form 2801
For use of this form, see AR 195-6; the proponent is PMG.
Should you refuse to undergo a polygraph examination, no adverse action may be taken against you based solely on your refusal.
You have the right to talk privately with a lawyer before, during and after the polygraph examination.
The examination area is equipped with a two-way mirror or observation device, and the examination will be monitored/recorded.
Questioning may occur before, during and after the instrument portion(s) of the polygraph examination.
Anything you say or do during the polygraph examination may be used against you in your administrative, military or judicial proceedings.
The polygraph examination will not be conducted without your voluntary consent, and even though you are now giving your consent, you can withdraw it at any time and the examination will be stopped.
You consent of your own free will to undergo a polygraph examination, and you have not been threatened, coerced, unlawfully induced or promised anything in conjunction with your consent to undergo a polygraph examination.
Sources
[1] DA Form 2801 (JUN 2011), Polygraph Examination Statement of Consent, U.S. Army (the Official source link on this page).