Maryland Polygraph Police Form – Fill Out and Use This PDF

The Maryland Polygraph Police form is a crucial document that is part of the application process for those seeking employment with the Maryland State Police, including positions such as Trooper, Cadet, Civilian, and roles within Allied Agencies. It requires applicants to provide comprehensive personal, background, and employment information, and is used alongside a pre-employment polygraph examination to verify the truthfulness and integrity of the prospective employee. This form and the accompanying polygraph test are steps designed to maintain the high standards of honesty and trust required by the Maryland State Police.

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Maryland Polygraph Police Form PDF Details

The Maryland State Police Applicant Polygraph Screening Booklet serves as a critical piece in the employment process, designed to ensure the utmost honesty and integrity among potential hires. Aimed at positions ranging from Trooper and Cadet to Civilian and Allied Agency roles, this comprehensive document begins by ascertaining a candidate's serious intent through a conditional offer of employment query. Probing further, it establishes a strong foundation for truthfulness, explicitly stating the significance of candid responses for a role within law enforcement where trust and responsibility are paramount. A detailed personal background check forms the cornerstone of this process, meticulously examining facets such as identity, citizenship, residency, and more, calling for absolute transparency regarding past actions and affiliations, including any legal alterations to personal identity or instances of holding citizenship in countries other than the United States. Additionally, the form ventures into the domains of residency stability and moral conduct, interrogating potential evictions, financial delinquencies, and interpersonal disputes, aiming to sketch a comprehensive moral and ethical portrait of the applicant. This scrutiny underscores the rigorous standards upheld by the Maryland State Police, ensuring that each candidate's integrity is thoroughly vetted through a polygraph examination before any commitments are made, reflecting the department's diligent approach to fostering a trustworthy and reliable law enforcement body.

Question	Answer
Form Name	Maryland Polygraph Police Form
Form Length	29 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min 15 sec
Other names	md polygraph state police, maryland state police polygraph, msp form polygraph screening printable, maryland form polygraph

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Assigned to: _____________________

Tracking 67# ____________________

MARYLAND STATE POLICE APPLICANT POLYGRAPH SCREENING BOOKLET

Position Applied For:

Trooper Cadet

Civilian

Allied Agency

Other_

Have you received a written Conditional Offer of Employment? Yes No

INSTRUCTIONS TO APPLICANT:

You are being considered for employment with the Maryland State Police. As a prerequisite for employment, you are required to submit to a pre-employment polygraph examination. As part of that process, it will be necessary for you to complete this booklet. The contents of this booklet are held "CONFIDENTIAL," except when essential to the conduct of proper official police business and national security. It is important that you understand that the intentional misrepresentation, omission, or falsification of any material fact may be just cause for disqualification or dismissal from the applicant process.

Maryland State Police employees, regardless of position, are placed in a position of trust and responsibility. Because of this trust, the MSP expects candor and honesty from all employees. The purpose of this examination is to determine the truthfulness of the information provided to the polygraph examiner. The areas of inquiry will deal with your background and experience.

During the interview with the polygraph examiner, you will discuss many aspects of your background. Some may seem so "bad" that you are afraid it will disqualify you from this job. What will disqualify you is your failure to provide truthful, accurate, and complete information.

The next page is your written permission for the examiner to administer your examination. Do not mark on the page except to sign it in the lower right corner marked "signature."

Name (Last, First Middle) ________________________________________________________

Date of Birth_____________ Driver's License Number / State ____________________________

Mailing Address _______________________________________________________________

City ________________ County ______________ State __________ Zip Code ___________

Telephone: Home________________ Work _______________Cell Phone ________________

E-mail address ________________________________________________________________

Current Employer ______________________________________________________________

Employment Address ___________________________________________________________

City ________________ County ______________ State __________ Zip Code ___________

Date Booklet Completed: ___________________

MSP 40-23 (09-16)

RELEASE

I hereby voluntarily submit to a polygraph examination (detection of deception) by the Maryland State Police. I understand and agree that the polygraph examination will be audio and video recorded and that the recordings as well as the results of the polygraph examination may be made available to the proper authorities. In consideration of being given a polygraph examination without cost to me, I, for myself, my heirs, personal representatives and assigns, hereby agree to hold harmless, the Maryland State Police, its officers, employees, and agents from any liability for any damage to me as a result of said examination and I hereby remise, release, waive, and forever discharge and exonerate said Maryland State Police, its officers, employees, agents from any and all action or cause of action, claim, or demand which I have now or may ever have resulting directly, indirectly, or remotely from said examination or making known any reactions, statements, information, and incidental opinions made by me as part of the examination.

In witness whereof, I have hereunto set my hand and seal the day and date set forth above.

_________________________________	____________________________
WITNESS	SIGNATURE / DATE

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION

PART 1: IDENTITY

Full Name: (Last, First Middle):____________________________________________________________________

Date of Birth: _________________ Race:________ Gender:_________ Place of Birth: _____________________

Social Security Number: _________________________________________________________________________

Scars, marks, or tattoos: (explain any significance) ____________________________________________________

_____________________________________________________________________________________________

Excluding nicknames, list any other names you have ever used and the periods of time you used them:

_________________________________________________________________________________________________

YES NO

Has your name ever been changed by court order?

Have you ever used a false name, date of birth, or place of birth for any reason? Have you ever obtained, possessed, or used any form of false identification? Have you ever used a false Social Security Number or someone else’s SSN? Have you ever misrepresented your identity to any law enforcement agency? Have you ever falsified your identity on any job application?

Have you ever falsified your identity on any credit application?

Have you ever falsified your identity on any other application or official document?

While underage, did you ever use any type of false identification to buy alcoholic beverages?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 1 - IDENTITY:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 2: CITIZENSHIP

YES NO

____ ____ Have you ever held citizenship in any country other than the United States?

IF YOU ANSWERED “YES” TO THE ABOVE QUESTION, YOU MUST ALSO ANSWER THE BELOW QUESTIONS ON THIS PAGE. IF YOU ANSWERED “NO” TO THE ABOVE QUESTION, YOU DO NOT HAVE TO ANSWER THE BELOW QUESTIONS ON THIS PAGE. PROCEED TO SECTION A, Part 3 (page 6).

Excluding the United States, list all foreign countries where you have held citizenship and the periods of time for each:

_________________________________________________________________________________________________

In what country were you born?________________________________________________________________________

At what age did you leave your country of birth? _________ At what age did you come to the U.S.?_______

Why did you leave your country of birth?_________________________________________________________________

Why did you come to the U.S.?________________________________________________________________________

With whom did you come to the U.S.?___________________________________________________________________

To what country do you hold your primary allegiance (loyalty)? _______________________________________________

YES NO

Have you ever worked for a foreign government or foreign law enforcement agency? Have you ever been a member of a foreign military service?

Have you ever worked for, or been affiliated in any way, with a foreign intelligence agency? Are you now a Naturalized United States Citizen?

Have you provided this department with a valid Naturalization Certificate? Do you possess a valid passport issued by a foreign country?

Have you taken part in committing any crime(s) in another country?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 2 – CITIZENSHIP:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 3: RESIDENCY

List your current home address: _______________________________________________________________________

List any other addresses where you stay on a regular basis: _________________________________________________

_________________________________________________________________________________________________

	YES		NO
1.				Have you ever been evicted or threatened with eviction from any places you have lived?


2.				Have you ever had a mortgage foreclosure taken against you?


3.				Excluding eviction or foreclosure, have you ever been ordered to vacate any place you have lived?


4.				Have you ever been forced to vacate housing at any colleges due to disciplinary problems?


5.				Have you ever received a notice to appear in Landlord-Tenant Court?
5.
6.				Do you reside at any other address on a regular basis?
6.				Do you reside at any other address on a regular basis?

7.		____	____	Have you ever broken a lease at any place you lived?
7.		____	____	Have you ever broken a lease at any place you lived?
8.				Have any liens been placed against any property you have owned?
8.
9.				Have you had any police contact while leasing or renting?


10.				Have you been involved in any arguments or fights with any of your neighbors?
10.
11.				Will any of your current or former neighbors say anything derogatory about you?


12.				Have you ever moved out of any place you have lived due to arguments or disputes with your spouse,
12.
				family members, roommates, neighbors, or landlords?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 3 - RESIDENCY:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 4: EDUCATION

Name of High School Attended: ________________________________ Dates Attended: ______________________


Address: ______________________________________________________ Diploma Received: Yes	No
	No

Highest Grade Completed: ______ Graduation Date: __________ High School Equivalency (GED): Yes		No
		No

COLLEGES / UNIVERSITIES ATTENDED (Include name, address, # of credit hours, major, degree received)

YES NO

10.

11.

12.

13.

14.

15.

Were you ever suspended or expelled from any type of learning establishment for any reason? Did you ever have any adverse contact with high school security or school police?

Were you ever taken into custody or charged with any crimes by high school security or police? Did you ever have any adverse contact with college campus security or college police?

Were you ever taken into custody or charged with any crimes by campus security or police? Were you ever questioned as a suspect in any crimes by campus security or police?

Were you ever ineligible to return to any high school or college due to disciplinary reasons? Were you ever barred from entering the property of any high school or college?

Did you ever have any adverse contact with any resident assistants?

Were you ever required to appear before any college hearing board as a result of disciplinary action? Did you ever cheat on any exams, tests, assignments, projects, or papers in high school or college? Were you ever caught cheating in any educational or training environment?

Did you ever falsify your high school or college grades or grade point average? Did you ever falsify any information on your high school or college transcripts? Did you ever have any academic/disciplinary probations in high school or college?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 4 - EDUCATION:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 5: EMPLOYMENT

Please list places of employment starting from most recent. Also include dates employed. (If needed, use additional space provided in the remark sections)

YES NO

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

	Have you ever been fired from any job?
	Have you ever been allowed to resign from any job in place of being fired?
	Have you ever quit any job because you thought you were going to get fired?
_	Are you ineligible for rehire at any place of employment now?
	Have you ever been denied any merit increases due to poor performance evaluations?
	Have you ever been involved in any physical or verbal confrontation with any coworker, supervisor,
	or customer?
	Have you ever quit any job due to allegations of misconduct on your part?
	Have you ever received any written disciplinary action on any jobs?
	Have you ever been suspended (with or without pay) from any job?
	Have you ever been investigated for any criminal acts against any of your employers?
	Have you ever been involved in industrial or corporate espionage?
_	Have you ever committed any criminal acts against any of your employers or coworkers?
	Have you ever deliberately violated any serious employment rules or regulations?
	Have you ever deliberately violated any employment nondisclosure agreements?
	Have you ever been denied employment due to adverse results of a background investigation?
	Have you ever applied to any police department or law enforcement agency?
	Have you ever been employed by any police department or other law enforcement agency?
	Have you ever been rejected for employment by any police department or law enforcement agency?
	Have you ever had any prior polygraph examination? If “Yes”, list when, where, and results.
	Have you ever before made application for employment with the Maryland State Police? If yes, when,
	what position, and what is the status of that application.

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 5 - EMPLOYMENT:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 6: FINANCES / CREDIT / LAWSUITS

YES NO

Have you ever declared bankruptcy?

Have any court ordered financial judgments ever been taken against you? Have you ever had any property repossessed?

Have you ever had any accounts taken over by a collection agency? Are any of your current debts or bills 30 or more days delinquent? Have any liens been placed against any property you have owned?

Have you ever been sanctioned by the IRS or any state income tax agency? Do you have any alimony or child support obligations?

IF YOU ANSWERED “YES” TO ANY OF THE ABOVE QUESTIONS, STATE WHAT SPECIFIC ACTIONS YOU TOOK OR ARE NOW TAKING TO RESOLVE THESE FINANCIAL PROBLEMS.

_________________________________________________________________________________________________

YES NO

10.

11.

12.

13.

Have your wages ever been garnished?

Has anyone ever sued you?

Have you ever sued anyone?

Have you ever received any out of court settlements?

Have any of your bank accounts ever been garnished or frozen?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 6 - FINANCES / CREDIT / LAWSUITS:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 7: MILITARY SERVICE

YES NO

Have you ever served in any branch of the Unites States military? Have you ever been rejected by any branch of the military?

Have you ever served in, or attempted to enlist in, any branch of a foreign military? Have you registered for selective service?

IF YOU SERVED IN THE MILITARY (U.S. OR FOREIGN) YOU MUST ALSO ANSWER THE FOLLOWING QUESTIONS. IF YOU HAVE NOT SERVED IN THE MILITARY, YOU DO NOT HAVE TO ANSWER THE BELOW QUESTIONS AND CAN NOW PROCEED TO SECTION 8.

YES NO

Did you receive an Honorable Discharge? (IF NO, EXPLAIN)

Were you ever court-martialed?

Did you ever receive any nonjudicial punishments (written or verbal reprimand, etc.)? Were you ever questioned as a suspect in any crimes by any U.S. or foreign military police? Did you ever have any adverse contact with any U.S. or foreign police?

Were you ever denied eligibility for re-enlistment?

Were you ever charged with any violations of the Uniform Code of Military Justice (UCMJ)? Have you ever altered a copy of your DD-214 during any pre-employment investigation?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 7 - MILITARY SERVICE:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

PART 8: DRIVER’S LICENSE / RECORD / ACCIDENTS

YES NO

10.

11.

12.

13.

14.

15.

Have you ever operated a vehicle after consuming any intoxicating substance to the point of impairment?

Have you ever operated a vehicle after consuming any intoxicating substance to the point of intoxication?

Have you ever fled from, or attempted to elude, police while on foot or in a vehicle? Have you ever operated a motor vehicle knowing it was uninsured / unregistered? Have your license plates ever been confiscated by the police or MVA?

Has your vehicle insurance ever been canceled or denied renewal? Have you ever failed to appear in court as a result of any traffic ticket? Have you ever received any traffic tickets as a result of a traffic accident? Have you ever been involved in any law-suit as a result of a traffic accident? Have you ever been involved in a hit and run accident?

Have you ever lied to any police officers to try to get out of a traffic ticket?

Have you ever lied to a judge in traffic court?

Do you currently have any traffic or parking tickets for which you have not paid the fine or appeared in court for?

Have you ever had a driver’s license in any other state? If so, list the periods of time for each? Have you ever filed to have any violations expunged from your driving record? If so, explain.

List below all traffic stops in this state or any other state that resulted in you receiving any of the following: citations, written warnings, verbal warnings, Safety Equipment Repair Orders, red light tickets, speed camera tickets.

DATE

STATE

VIOLATION(S)

DISPOSITION

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

List below all accidents you have been involved in while operating a motor vehicle. (Include date, whether or not it was investigated by the police, and who was charged with being at fault.)

DATE

STATE

POLICE INVESTIGATION (YES OR NO)

DISPOSITION

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 8 - DRIVER’S LICENSE / RECORD / ACCIDENTS:

_____________________________________________________________________________________

_________________________________________________________________________________________________

PART 9: ALCOHOLIC BEVERAGE USE

YES NO

Have you ever blacked out, passed out, or incurred any loss of memory due to excessive drinking?

Have you ever drunk too much because you were depressed?

Have you ever been rejected for employment by any law enforcement agencies due to your drinking habits or problems in your life due to drinking?

Have you ever been stopped or detained by any law enforcement authorities for suspicion of driving while intoxicated or impaired?

Have you ever been arrested, or received any criminal charges or citations for any alcohol related offenses?

Have you ever consumed alcoholic beverages during working hours on any jobs in violation of employment rules or regulations?

Have you ever been in any verbal or physical fights with anyone as a result of your drinking?

While an adult, have you furnished or provided alcoholic beverages to any person(s) you knew were underage (excluding your own children)? Please provide the details in the table below.

DATE PROVIDED

(IF EXACT DATE UNKNOWN, LIST

APPROXIMATE MONTH AND YEAR PROVIDED)

NAME AND AGE OF PERSON(S) TO

WHOM YOU PROVIDED

TYPE AND AMOUNT OF ALCOHOLIC

BEVERAGE PROVIDED

10.

11.

Have you ever falsified your identity to buy alcoholic beverages while underage?

Have you ever consumed alcoholic beverages while underage? How many times? ______ Date of most

recent occasion? (If exact date unknown, list approximate month and year)

Have you ever been issued a citation for any underage alcohol violation?

How many times have you operated a motor vehicle when you have been under the influence, to any degree, of alcoholic beverages? __________________________ When was the last incident? ___________________________

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

How many times have you operated a motor vehicle while you were consuming alcoholic beverages? __________

When was the last incident? ___________________________

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 9 - ALCOHOLIC BEVERAGE USE:

_________________________________________________________________________________________________

PART 10: ARRESTS / CRIMINAL CHARGES / CRIMINAL INVESTIGATIONS

YES		NO
1.				As an adult or juvenile, have you ever been arrested?
1.				As an adult or juvenile, have you ever been arrested?
2.				As an adult or juvenile, have you ever received a criminal/civil summons or citation for a violation of any
2.
				law?
3.				Have you ever received an underage alcohol citation?


4.				Have any criminal charges against you ever been dropped or dismissed?


5.				Have you ever received probation before judgment (PBJ) for any criminal charges?


6.				Have you ever been granted immunity from prosecution for any criminal charges?


7.	____		____	Have you ever accepted a plea bargain for any criminal charges?
7.	____		____
8.				Do you currently have any criminal charges pending payment of fine or court disposition?



9.	____			Have you ever been investigated or interviewed by any law enforcement or security personnel
9.	____
				as a suspect in any crime?
10.				As an adult or juvenile, have you ever received a criminal/civil summons or citation for a violation of any


				town/city/municipality code or ordinance?

MSP 40-23 (09-16)

SECTION A: PERSONAL BACKGROUND INFORMATION (Continued)

YES NO

10.

11.

12.

13.

14.

Have you ever been concerned that you were under investigation for commission of any crimes even though you were not directly contacted by any law enforcement authorities?

Have you ever pled guilty or been found guilty of any criminal charges?

Have you ever been placed into a jail, prison, or detention center as a result of criminal charges?

Are you currently wanted in any jurisdiction for any reason?

Have you ever been on parole or probation?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION A, PART 10 - ARRESTS / CRIMINAL CHARGES / CRIMINAL INVESTIGATIONS:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION B: FAMILY / DOMESTIC VIOLENCE ISSUES

MOTHER

FATHER

GUARDIAN

INCLUDE NAME, ADDRESS, AND WHETHER LIVING OR DECEASED

SIBLING 1.

SIBLING 2.

SIBLING 3.

SIBLING 4.

INCLUDE FULL NAME AND AGE

SPOUSE

FORMER SPOUSE

SIGNIFICANT OTHER

FORMER SIGNIFICANT

OTHER

INCLUDE FULL NAME, AGE, ADDRESS, LENGTH OF RELATIONSHIP (Significant Other to include boyfriend, girlfriend, fiancé, life partner)

CHILD 1.

CHILD 2.

CHILD 3.

CHILD 4.

INCLUDE FULL NAME AND AGE

YES NO

Have the police ever responded to any domestic violence incident in which you were involved?

Have you ever been involved in any domestic violence incident when the police did not respond?

Have you ever received any of the following court orders against you: ex parte, restraining order, protective order, peace order, or any other court order naming you as a defendant?

Have you ever been investigated by any authority for allegations of physical child abuse or child neglect?

Have you ever inflicted any physical injury to any child who was in your care and custody?

Have you ever been involved in any physical confrontation during any domestic dispute?

Have you ever used a weapon or threatened anyone with a weapon during any domestic dispute?

Have you ever damaged the personal property of another during any domestic dispute?

Will any of your former spouse(s), fiancé(s), boy or girl friend(s), domestic or life partner(s), or significant others provide any adverse or derogatory information about you?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION B - DOMESTIC VIOLENCE:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION C: SEXUAL CRIME ISSUES

YES NO

10.

11.

Have you ever had sexual contact with any child under the age of 18 when you were four or more years older than that child? (Include whether or not you paid the child in any form to participate in the sexual contact.)

Have you ever intentionally viewed, possessed, distributed, or manufactured any form of child pornography?

Have you ever had, or attempted to have, sexually explicit conversations with a child via a computer or any other media outlet?

Have you ever engaged in any sexual acts involving prostitution, to include committing the act of prostitution, arranging the services of a prostitute, or profiting from those services?

Have you ever engaged in sexual contact with any animal?

Have you ever committed, participated in, or facilitated an act of rape?

Have you ever sexually touched another person against their will and without their consent?

Have you ever committed any sexual act with another person against their will or when the other person was unable to consent or resist due to a disabling condition such as intoxication or any physically or mentally incapacitating condition or event?

Have you ever exposed your sexual parts to harass, frighten, or shock another person?

Have you ever had inappropriate sexual contact with any family member?

Have you ever video recorded/taped/photographed a sex act(s) without the consent/knowledge of the other person(s) involved?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION C - SEXUAL CRIMES:

_______________________________________________________________________________________________

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION D: SERIOUS CRIME ISSUES

YES NO

Have you ever taken part in committing a burglary or breaking and entering?

Have you ever forged any documents for financial gain or criminal intent?

Have you ever taken part in committing arson or malicious burning?

Have you ever taken part in the malicious destruction of another person’s property? Have you ever taken part in committing computer hacking or computer crimes?

Have you ever taken part in the manufacture or detonation of bombs or explosive devices? Have you ever made a false bomb threat, false fire alarm call, or false 911 call?

Have you ever committed any form of animal cruelty? (does not include lawful hunting)

Have you ever taken part in committing any other crime(s) against property not specifically listed in the above questions?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION D, PART 1 - SERIOUS CRIMES AGAINST PROPERTY:

_______________________________________________________________________________________________

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION D: SERIOUS CRIME ISSUES (Continued)

PART 2: SERIOUS CRIMES AGAINST PERSONS

YES NO

1. Have you ever been criminally involved in the death of a person (murder, manslaughter)?

2. Have you ever taken part in committing an armed robbery?

3. Have you ever taken part in committing a strong-arm robbery, mugging, or purse snatching?

4. Have you ever assaulted anyone with any type of weapon?

5. Excluding the use of weapons, have you ever physically assaulted anyone?

6. Have you ever seriously injured anyone as a result of assaulting them?

7. Have you ever taken part in a kidnapping, abduction, or false imprisonment?

8. Have you ever stalked or criminally harassed anyone?

9. Have you ever made any threats of bodily harm to anyone?

10. Have you ever taken part in committing blackmail or extortion?

11. Have you ever taken part in illegal gambling?

12. Have you ever impersonated yourself as a police officer or other law enforcement agent?

13. Have you ever taken part in committing any other crime(s) against persons not specifically listed in the above questions?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION D, PART 2 - SERIOUS CRIMES AGAINST PERSONS:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION D: SERIOUS CRIME ISSUES (Continued)

PART 3: SERIOUS CRIMES INVOLVING TERRORISM / HOMELAND SECURITY

YES NO

3._

10.

11.

12.

Have you ever been affiliated with any organizations, groups, gangs, or persons who would seek to engage in acts of violence toward the United States government, military, businesses, or citizens?

Have you ever been affiliated with any organizations, groups, gangs, or persons who support or advocate any acts of terrorism toward the United States government, military, or any U.S. business or citizen?

Have you ever taken part in any anti-U.S. rallies, meetings, marches, or protests?

Have you ever taken part in any acts of treason against the United States?

Have you ever taken part in committing sabotage or espionage against the United States?

Have you ever donated any money, time, or services to any anti-U.S. organizations?

Have you accessed any information from any sources about techniques of beating, cheating on, or using countermeasures on polygraph examinations?

Have you accessed any information from any sources about methods used to cheat on voice stress tests, urinalysis tests, psychological tests, background investigations, or any other aspects of personnel security screening?

Have you ever been granted a security clearance by the U.S. Government?

Was your security clearance ever suspended or taken away from you due to any allegations of wrong doing on your part or investigations into such activities?

Have you ever been involved in any activities, behaviors, or incidents that someone could use against you for blackmail?

Is there anything you would like to explain or clarify concerning potentially adverse or derogatory information which may be developed about you during a police background investigation?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION D, PART 3 – SERIOUS CRIMES INVOLVING TERRORISM / HOMELAND SECURITY:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION E: THEFT ISSUES

(The questions in this Section are about your involvement as a perpetrator in the commission of thefts. These questions pertain to any thefts you know you were involved in committing, either directly, indirectly, or as an accomplice or conspirator; and, whether or not you were caught, arrested, charged, or if only you know about the crime.)

YES NO

10.

11.

12.

13.

14.

15.

16.

Have you ever shoplifted any merchandise from a store?

Have you ever helped anyone shoplift (lookout, divert store employees, hide merchandise, etc.)? Have you ever stolen any money, merchandise, or property from any place you have worked? Have you ever stolen any money, merchandise, or property from any of your coworkers?

Excluding places where you have worked or shoplifted from, have you ever stolen any money, merchandise, or property from any other place or anyone else?

Have you ever returned any stolen merchandise to a store for an exchange or refund? Have you ever short-changed customers or over-rung sales and kept the extra money? Have you ever taken part in committing embezzlement?

Have you ever deliberately falsified any time cards, work schedules, expense accounts, payroll documents, purchase orders, bills, invoices, or any other financial document to commit a theft?

Have you ever knowingly received, purchased, or sold any stolen property?

Have you ever helped anyone steal any money, merchandise, or property?

Have you ever filed any false insurance claims?

Have you ever used someone’s credit card, bank card, debit card, ATM card, checking or savings accounts without that person’s permission?

Have you ever written any checks on an account you knew to be closed

Have you ever stolen from any governmental agency to include intentionally falsifying any income tax return?

Have you ever taken or stolen anything not specifically listed in the above questions?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION E – THEFTS:

_________________________________________________________________________________________________

_________________________________________________________________________________

MSP 40-23 (09-16)

SECTION F: ILLEGAL DRUG ISSUES

PART 1: ILLEGAL DRUG USAGE

Check YES or NO if you have ever tried, used, taken, swallowed, experimented with, or in any way ingested or injected any of the listed drugs. Please include information even if the use was legal in the jurisdiction in which you used the drug. You must provide accurate and specific information as required. Do not intentionally mis-state or understate the number of times you know you used or tried any drug, or the most recent date or age of your use.

For purposes of your polygraph examination and so that you can accurately indicate the number of times you used a particular drug, an example of what constitutes a “use” is, if you and a friend are at your house and smoke a marijuana joint together, that is one use, regardless of the number of inhalations taken off of that joint. If you and a friend get together after work the same day and meet at a park and smoke another marijuana joint, then that constitutes a second “use”, regardless of the number of inhalations.

Although both incidents occurred during the same day, they were separated by time and location and are considered two uses.

YES

DRUG

MONTH/YEAR/AGE FIRST USED MONTH/YEAR/AGE LAST USED # OF TIMES

Marijuana

Spice

Bath Salts

Hashish

Cocaine

Crack

LSD / Acid

Salvia

Mushrooms

Peyote

Other Hallucinogens

PCP

MDMA (Ecstasy)

GHB (Date Rape)

Special K / Ketamine

Methamphetamines

Heroin

Methadone

Morphine

Opium

Speed (Amphetamines)

Downers (Barbiturates)

Quaaludes

Steroids

Nitrous Oxide

Whippets

Glue

Gasoline

Paint Thinner

Non-Prescribed Narcotics

Other – List Substance below

MSP 40-23 (09-16)

SECTION F: ILLEGAL DRUG ISSUES (Continued)

Since the age of 21, how many times have you smoked marijuana? ______________________________

Since the age of 21, how many times have you used any illegal drug other than marijuana? ___________

Detail the extent of your illegal drug use within the last 3 years? ________________________________

_____________________________________________________________________________________________

PART 1: ILLEGAL DRUG USE (Continued)

YES	NO
1.		Have you ever used more than one type of illegal drug at the same time? (Marijuana + Cocaine; Marijuana +


		LSD; Hashish + Cocaine, etc.)
2.		Have you ever used illegal drugs in combination with alcoholic beverages?
3.		Have you ever used illegal drugs in combination with prescription or over the counter medicine?


4.		Have you ever blacked out, passed out, or incurred a loss of memory due to use of illegal drugs?
4.
5.		Have you ever used an illegal drug during working hours at any job?
5.
6.		Have you ever reported for work to any job while you were high or under the influence of illegal drugs?
6.
7.		Have you ever used an illegal drug while serving in the military?
8.		Have you ever used an illegal drug because you were depressed?
8.
9.		Have you ever received treatment, counseling, or therapy due to illegal drug use?
9.
10.		Have you ever experienced any adverse contact with law enforcement due to illegal drug use, possession, or


		distribution?
11.		Do any of your current close friends, roommates, or family members use illegal drugs?
11.
12.		Do any of your close coworkers use illegal drugs?
12.		Do any of your close coworkers use illegal drugs?
13.		To your knowledge, do you know or suspect that there are any illegal drugs present in the house or apartment
13.
		where you currently live?
14.		Does anyone you currently associate with use any illegal drugs in your presence?
15.		Have you solicited any persons who may be contacted during your background investigation to falsify information
15.
		about your use or personal involvement with illegal drugs?
16.		Have you ever ingested any substances to attempt to interfere with or falsify the outcome of any drug analysis
16.
		tests, or any other tests you have taken?
17.		Have you ever given or dosed anyone with any illegal drugs without that person’s knowledge or permission?

18.		Has anyone ever overdosed from substance abuse in your presence?
18.
19.		Have you ever been issued a civil or criminal citation for a violation of any drug law?

When was the most recent time you were in the physical presence of anyone who was using illegal drugs?

___________

What type of illegal drug(s) was being used? ________________________________________________

Where did this take place? ________________________________________________________________

Who was using illegal drugs? (list names) ____________________________________________________

What was the specific extent of your involvement? ____________________________________________________

MSP 40-23 (09-16)

SECTION F: ILLEGAL DRUG ISSUES (Continued)

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION F, PART 1 - ILLEGAL DRUG USE:

_________________________________________________________________________________________________

PART 2: ILLEGAL DRUG TRANSACTIONS

YES NO

10.

11.

12.

13.

14.

15.__

16.

Have you ever directly purchased any illegal drugs?

Have you ever contributed any money toward the purchase of illegal drugs?

Have you ever received any money to purchase illegal drugs?

Have you ever loaned anyone any money to purchase illegal drugs?

Have you ever traded anything to receive illegal drugs?

Have you ever performed any services for anyone to receive illegal drugs?

Have you ever directly sold any illegal drugs?

Have you ever received any money from anyone who sold illegal drugs?

Have you ever received any property or merchandise for providing someone with illegal drugs?

Has anyone performed any services or favors for you as a result of providing them with illegal drugs?

Have you ever driven, taken, or directed anyone to any place to purchase or sell illegal drugs? Have you ever set up, arranged, or facilitated any illegal drug transactions?

Have you ever hidden any illegal drugs for yourself or anyone else?

Have you ever knowingly transported any illegal drugs in a vehicle, boat, plane, or other conveyance? Have you ever distributed any illegal drugs?

Have you ever bought any illegal drugs over the Internet?

MSP 40-23 (09-16)

SECTION F: ILLEGAL DRUG ISSUES (Continued)

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION F, PART 2 - ILLEGAL DRUG TRANSACTIONS:

_________________________________________________________________________________________________

_______________________________________________________________________________________________

PART 3: GROWING/MANUFACTURING/SMUGGLING ILLEGAL DRUGS

	YES		NO
1.						Have you ever grown or attempted to grow Marijuana or any other illegal drugs?


2.				____		Have you ever helped anyone grow or attempt to grow Marijuana or any other illegal drugs?
2.				____
3.						Have you ever taken part in manufacturing any illegal drugs?
3.
4.					____	Have you ever taken part in producing any illegal drugs?
4.					____	Have you ever taken part in producing any illegal drugs?
5.						Have you ever taken or attempted to take any illegal drugs into or out of the United States?
5.
6.						Have you ever taken or attempted to take any illegal drugs into or out of any foreign country?
6.
7.		____			____	Have you ever used any illegal drugs, which are classified as illegal in the U.S., in any foreign
7.		____			____
						countries where they are legal to use?
8.						Have you ever bought any illegal drugs, which are classified as illegal in the U.S., in any foreign
8.
						countries where they are legal to buy?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION F, PART 3 - GROWING/MANUFACTURING/SMUGGLING ILLEGAL DRUGS:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

SECTION F: ILLEGAL DRUG ISSUES (Continued)

PART 4: ILLEGAL USE OF PRESCRIPTION MEDICINE

YES NO

10.

11.

12.

13.

14.

Have you ever ingested any prescription medicine for non-medical reasons? (to get high, out of curiosity, for social or recreational reasons, etc.)

Have you ever ingested any over the counter medicine for non-medical reasons?

Have you ever illegally bought any prescription medicine to include, but not limited to, Percocet, Oxycontin, Oxycodone, etc?

Have you ever illegally sold any prescription medicine to include, but not limited to, Percocet, Oxycontin, Oxycodone, etc?

Have you ever traded anything for prescription medicine?

Has anyone ever given you any prescription medicine for non-medical reasons? Have you ever given anyone any prescription medicine for non-medical reasons?

Have you ever performed any services for anyone in order to receive prescription medicine? Has anyone ever performed any services for you in exchange for prescription medicine? Have you ever intentionally over-medicated or over-dosed yourself?

Have you ever sought any prescriptions for any medicines with the intent to use them to get high? Has there ever been a time in your life when you were addicted to any prescription medications?

Have you ever secretly given anyone any prescription medicine without that person’s knowledge or consent?

Have you ever taken part in any prescription forgeries?

WRITTEN EXPLANATIONS FOR ANY “YES” ANSWERS TO SECTION F, PART 4 - ILLEGAL USE OF PRESCRIPTION MEDICINE:

_________________________________________________________________________________________________

MSP 40-23 (09-16)

READ FIRST BEFORE PROCEEDING

TO THE NEXT SECTION

THE QUESTIONS IN THE FOLLOWING SECTION “G” PERTAIN TO PERSONS WHO HAVE BEEN EMPLOYED IN LAW ENFORCEMENT, POLICE, SECURITY, INTELLIGENCE, INVESTIGATIVE, CORRECTIONAL, AND ALLIED CRIMINAL JUSTICE POSITIONS.

IF YOU HAVE BEEN EMPLOYED IN ANY OF THE FOLLOWING JOBS, YOU MUST ANSWER THE QUESTIONS IN SECTION “G”:

•SWORN POLICE OFFICER

•CADET

•DEPUTY SHERIFF

•SECURITY OFFICER / GUARD

•MILITARY POLICE

•INVESTIGATOR FOR ANY FEDERAL, STATE, COUNTY, OR MUNICIPAL AGENCY

•PROTECTIVE SERVICES / SOCIAL SERVICES INVESTIGATOR

•PRIVATE INVESTIGATOR

•FEDERAL AGENT

•U. S. MARSHAL

•CORRECTIONAL OFFICER

•PAROLE / PROBATION AGENT OR INVESTIGATOR

•INVESTIGATOR FOR ANY PROSECUTOR’S OFFICE, DISTRICT ATTORNEY OR COURT

•INTELLIGENCE AGENT, OFFICER, OR ANALYST

•JUVENILE INTAKE OFFICER

•EMERGENCY COMMUNICATIONS OPERATOR

•POLICE DEPARTMENT INTERN

•FORENSIC OR CRIME LAB PERSONNEL

•CIVILIAN EMPLOYEE OF ANY POLICE DEPARTMENT, SECURITY AGENCY, INTELLIGENCE AGENCY, CORRECTIONAL AGENCY, INVESTIGATIVE AGENCY, OR TRAFFIC, CRIMINAL, OR CIVIL COURT SYSTEMS.

IF YOU HAVE NOT BEEN EMPLOYED IN ANY OF THE ABOVE JOBS, YOU DO NOT HAVE TO ANSWER THE QUESTIONS IN SECTION “G”.

MSP 40-23 (09-16)

SECTION G: CURRENT OR PRIOR LAW ENFORCEMENT QUESTIONNAIRE

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

YES NO

Have you ever accepted any bribes in exchange for failing to perform your official duties?

Have you ever used excessive force while handling any person in custody?

Have you ever used excessive force while handling any citizens or members of the public?

Have you ever lied or covered up for other police officers, correctional officers, or other criminal justice system employees whom you know have used excessive force?

Have you ever solicited any persons to lie about your own actions of using excessive force?

Have you ever falsified any reports or official documents with the intent to deceive?

Have you ever deliberately leaked confidential police information regarding any investigations, surveillances, stake-outs, raids, or any other police operations?

Have you ever discharged any firearm in violation of departmental or agency regulations?

Have you ever allowed an unauthorized persons to use, carry, possess, or discharge your service weapon or other departmental firearms?

Have you ever failed to submit any found, confiscated, or seized items to the property or evidence room as mandated by your department’s regulations?

Have you ever kept any found, confiscated, or seized items for personal use?

Have you ever taken anything from the evidence room in violation of departmental regulations?

Have you ever taken anything from arrestees, prisoners, inmates, or detainees and failed to account for or submit the item(s) as mandated by your department’s regulations?

Are you now in possession (at your residence, in your personal vehicle, etc.) of anything that you know should be accounted for or submitted to your department’s property or evidence room?

Have you ever been fired from any law enforcement, security, investigative, intelligence, corrections, or other allied criminal justice system job?

Have you ever been allowed to resign in place of being fired from any law enforcement, security, investigative, intelligence, corrections, or other allied criminal justice system job?

Have you ever deliberately associated with any person(s) you knew was involved in criminal activity or illegal drug use, transactions, production, or smuggling?

Have you ever been involved with the transportation of any illegal drugs into any correctional facility?

Have you ever provided an inmate or prisoner with any type of contraband? (tobacco products, cell phones, alcohol, magazines, etc.)

Have you ever been involved in an internal investigation other than as the investigator? If so, please provide all details.

Have you ever engaged in any sexual contact with any prisoners, arrestees, or detainees?

Have you illegally used any drugs while employed as a law enforcement officer?

MSP 40-23 (09-16)

WRITTEN EXPLANATIONS FOR SECTION G: CURRENT OR PRIOR LAW ENFORCEMENT:

_________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________________________________________________________________

THIS SPACE PROVIDED FOR ADDITIONAL RESPONSES TO ANY PREVIOUS QUESTION IN THE SCREENING BOOKLET (MAKE COPIES IF ADDITIONAL SPACE IS NECESSARY):

_________________________________________________________________________________________________

MSP 40-23 (09-16)

THIS SPACE PROVIDED FOR ADDITIONAL RESPONSES TO ANY PREVIOUS QUESTION IN THE SCREENING BOOKLET (MAKE COPIES IF ADDITIONAL SPACE IS NECESSARY):

_________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________________________________________________________________

_________________________________________________________________________________________________

MSP 40-23 (09-16)

THIS SPACE PROVIDED FOR ADDITIONAL RESPONSES TO ANY PREVIOUS QUESTION IN THE SCREENING BOOKLET (MAKE COPIES IF ADDITIONAL SPACE IS NECESSARY):

_________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________________________________________________________________

_________________________________________________________________________________________________

MSP 40-23 (09-16)

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