REFUSED TO WAIVE WAIVED PASSED

ORANGE COUNTY SHERIFF’S DEPARTMENT

PRE-INVESTIGATIVE INTERVIEW
(Sworn / Peace Officer Positions)

As a part of the selection process, applicants must pass a background investigation to the satisfaction of the Orange County
Sheriff’s Department prior to a job offer being made [CA Govt. Code §1029, 1030, 1031, 1031.1]. The attached
questionnaire is a part of that selection process and requests basic information regarding illegal drug use, criminal history,
employment, military service, credit, and other areas. This form is designed to aid staff members in conducting a
preliminary background interview. More detailed questions regarding these and other areas will be asked as the
background investigation continues.

COMPLETE AND HONEST ANSWERS TO EVERY QUESTION MUST BE PROVIDED IN ORDER TO CONTINUE IN THE
SELECTION PROCESS. ANY FAILURE TO PROVIDE FULL DISCLOSURE WILL BE CAUSE TO REMOVE THE APPLICANT FROM
THE RECRUITMENT PROCESS OR FROM IMMEDIATE DISMISSAL IF AN APPOINTMENT HAS ALREADY BEEN MADE.

THE SELECTION PROCESS ALSO INCLUDES A POLYGRAPH EXAMINATION. This examination must be successfully
completed to the satisfaction of the Orange County Sheriff’s Department in order to continue in the selection process,
and will include follow-up questions regarding the areas addressed on this pre-investigative questionnaire.

I have read and understand the above and affirm the answers given to be accurate and complete to the best of my
knowledge. I further acknowledge my option to withdraw from the hiring process prior to answering the pre-investigative
questions.

Signature: SS#:

Print First Name Middle Name Last Name

Street Address:

City: State: Zip:

Home Phone#: Work#: Mobile#:

DOB: DL#/State:

E-mail Address: Today’s Date:

Position Applying For:

STAFF MEMBER REVIEW:

Print Name

Signature

APPLICANT VOLUNTARILY WAIVED:

Print Name

Signature
 If you need more space for your answers, use the back of the page.

1. Have you EVER used, purchased, experimented with, ingested in any way, sold or provided to anyone, ANY illegal
drug? This includes marijuana and prescription drugs used without a valid prescription:

YES NO

If you answered YES, indicate the type of drug used, the way it was used, and the date you last used that drug. If
you sold or provided an illegal drug to someone else, indicate the type of drug sold or provided and the date this
occurred. Do not list the number of times you used an illegal drug.

Marijuana:
Cocaine:
Methamphetamine (Meth, Speed):
Heroin/Morphine (Methadone, OxyContin) (including prescription painkillers used without a valid prescription):

Hashish oil (wax):

Hallucinogens (LSD, PCP, Peyote, Mushrooms):
Steroids (oral or injected):
Ecstasy:
Nitrous Oxide:
GHB:
Inhalants (Paint, Glue, Gasoline, Freon, Solvents):
Amphetamines (Uppers):
Barbiturates (Downers):
Other illegal drug(s):

2. Have you associated with anyone who EVER used, purchased, experimented with, ingested in any way, sold or
provided to anyone, ANY illegal drug? This includes marijuana and prescription drugs used without a valid
prescription:

YES NO

If you answered YES, indicate the date, type of drug, and association.

Marijuana:
Cocaine:
Methamphetamine (Meth, Speed):
Heroin/Morphine (Methadone, OxyContin) (including prescription painkillers used without a valid prescription):

Hashish oil (wax):

Hallucinogens (LSD, PCP, Peyote, Mushrooms):
Steroids (oral or injected):
Ecstasy:
Nitrous Oxide:
GHB:
Inhalants (Paint, Glue, gasoline, Freon, Solvents):
Amphetamines (Uppers):
Barbiturates (Downers):
Other illegal drug(s):
3. If currently in any of the Armed Forces, list your separation date. If you were in the military, list the type of
discharge you received:

Separation Date

Never in any branch of the military, including reserve forces

Still Active
Honorable
Dishonorable
Medical
General, under honorable conditions
General, under less than honorable conditions

Other, explain (include any disciplinary action):

4. Have you EVER been fired or forced to resign from ANY job?

YES NO

If yes, explain when and why (do not include lay-offs):

5. Have you EVER been a SUSPECT in, or ARRESTED for ANY type of crime(s)? This includes both as a JUVENILE and
as an ADULT, and being cited in lieu of arrest for a criminal offense (i.e. petty theft, minor in possession of alcohol,
possession under one ounce of marijuana, drunk driving, etc.). Include any crime, which has been expunged, set
aside, dismissed, exonerated, etc. Do not include moving violations.

YES NO

If yes, include details (when, where, etc.):

6. Have you EVER committed any illegal act for which you were not arrested, i.e. theft, soliciting a prostitute, assault,
drunk driving, etc.?

YES NO

If yes, include details (when, where, etc):

7. Have you EVER been arrested for or accused of ANY assault upon anyone you have dated, cohabitated with, or
had a child with. Include any crime, which has been expunged, set aside, dismissed, exonerated, etc.?

YES NO

If yes, include details (when, where, charges, etc):

8. How many traffic citations and accidents have you received in the last seven (7) years? Include violations for
which you have attended traffic school, include any citation, which has been expunged, set aside, dismissed,
exonerated, etc.?

CITATIONS ACCIDENTS

For each traffic citation you have received, list the date, location, charge(s) and disposition.

9. Have you EVER filed, or do you plan to file, personal bankruptcy?

YES NO

If yes, list the date, type (chapter), amount, and explain the circumstances:

10. Have you EVER had an account go to collections?

YES NO

If yes, explain the circumstances:

11. Have you EVER had your wages garnished (taxes, child support, etc.)

YES NO

If yes, explain the circumstances:

12. Have you EVER applied for ANY position with the Orange County Sheriff’s Department?

YES NO

If yes, list year, position and status.

13. Have you EVER applied for a job with a law enforcement agency and not been hired?

YES NO

If yes, list date, agency, and disposition.

14. Have you EVER taken a polygraph examination or Voice Stress Analysis?

YES NO

If yes, list date, agency and disposition.

15. If it became necessary in order for you to protect your life or another person in the line of duty, would you be able
to use deadly force against another human being?

YES NO

Rev. 09/17 VP