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Sample Background Investigative Questionaire

Wonder what you’ll be asked in a background check? Here’s a sample provided by Battalion Chief Paul Lepore.

Read and answer the following questions carefully and honestly. Answers are subject to verification by a Polygraph Examination.

Have you ever committed any of the following acts during your life whether it came to the attention of authorities or not?

YES      NO

1. Spousal abuse (including common-law)…………………………………………………………………                         

2. Any violent assault upon another……………………………………………………………………………     

3. Forgery……………………………………………………………………………………………………………….     

4. Homicide…………………………………………………………………………………………………………….     

5. Robbery (theft from another person utilizing a weapon of force)…………………………………     

6. Burglary………………………………………………………………………………………………………………     

7. Kidnapping………………………………………………………………………………………………………….     

8. Arson (intentionally set fire)……………………………………………………………………………………     

9. Extortion (blackmail)……………………………………………………………………………………………..     

10. Embezzlement (theft of money)……………………………………………………………………………..     

11. Rape (sexual intercourse by force or against the wishes of another)…………………………..     

12. Child Abuse…………………………………………………………………………………………………………     

13. Child Molestation (any sex act with a child)……………………………………………………………..     

14. Prostitution (sexual acts for money or other considerations)………………………………………     

15. Soliciting Prostitution (asking for sex in return for money or visa versa)………………………     

16. Theft (including shoplifting)……………………………………………………………………………………     

17. Convicted of a DUI or charge reduced to reckless driving………………………………………….     

18. Have you in the past or do you now regularly associate with persons
whom you know to have engaged in and/or been arrested for unlawful
possession or use of any illegal substance?…………………………………………………………….     

19. Have you ever been arrested for an illegal sex act?………………………………………………….     

20. Ever charged with a crime not mentioned above?…………………………………………………….     

21. Have you ever been terminated or asked to resign from employment? ………………………     

22. Have you ever taken any property from an employer? ……………………………………………..     

23. Have you in any way falsified your employment application or made
any misleading statements?…………………………………………………………………………………..     

20. Ever charged with a crime not mentioned above?…………………………………………………….     

20. Ever charged with a crime not mentioned above?…………………………………………………….     

EXPLAIN ALL “YES” ANSWERS TO THE ABOVE QUESTIONS ON THE FOLLOWING PAGE.

Explain all “Yes” answers to the above questions in the spaces below. List the question # and then describe the incident. Be thorough with your explanation, use dates where appropriate.



Employees exempt from both overtime pay requirements and minimum wage.

Employees exempt from overtime pay requirements.

Employees of hospitals and residential care facilities compensated for overtime work on the basis of a 14-day work period.

Employees working under a “Belo” contract.

Board, lodging, or other facilities.

Tipped employees.

Learners, apprentices, messengers, students, or handicapped workers.

Individual home workers.

Agricultural employees. Time clocks are a good means of recording work hours, but they are not required. If there is a time clock, note that in addition to the timecard punches, the number of hours worked and the workweek should be written down. These figures may be noted on the timecard itself or on another record.


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