Background Investigation Questionaire

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Appendix A Background Investigation Questionnaire (BIQ)
Last Updated 06/14/2018

PURPOSE
• As a law enforcement agency, the Idaho Dept of Correction (IDOC) screens all applicants for
suitability to the position requested and conducts a criminal background check prior to an
offer of employment.
IMPORTANT
• Use only blue or black ink.
• Take your time and print legibly.
• Mark any unused spaces with N/A so we know you didn’t forget to fill it out.
• It is important that the information disclosed in this form is ACCURATE and COMPLETE to
the best of your knowledge.
o Being arrested for a crime, or terminated from an employer is not an automatic
disqualifier, but failure to disclose it may be.
• If you need more room for an answer DO NOT write on the back of the page. Please insert a
new page.
• You may be asked to begin employment prior to the results of fingerprinting. Continued
employment depends on the results of your fingerprints. If any information is discovered that
disqualifies you from continued employment, you will be asked to resign immediately from
IDOC employment.

DOCUMENTS
• You will need to provide a copy of the following documents with this packet.
o High School Diploma, Official High School Transcripts, GED, or Certificate
o Professional License or Certification (If listed)
o Military Service (DD-214 or NGB-22)
▪ To request military records go to http://www.archives.gov/veterans/military-
service-records/

QUESTIONS
• For clarification or questions please contact the IDOC’s Background Unit at
[e-mail] or go to
http://www.idoc.idaho.gov/content/careers/background_investigation_questionnaire.

_____________________________ _____________________ _________________
Last Name First Name Middle Name

___________________________________ _______________
Signature Date
IDAHO DEPARTMENT OF CORRECTION
BACKGROUND INVESTIGATION
QUESTIONNAIRE

INSTRUCTIONS

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Appendix A Background Investigation Questionnaire (BIQ)
Last Updated 06/14/2018
IDAHO DEPARTMENT OF CORRECTION
AUTHORIZATION TO RELEASE INFORMATION

As an applicant for employment with the Idaho Department of Correction (IDOC), I understand that
I am providing personal and employment history information to determine my qualifications and
suitability for employment with the Department, or for enrolling in the POST Academy, if requested.

I understand that I am voluntarily providing personal information such as my name, race, height,
weight, gender, date of birth, place of birth, driver’s license number, and social security number to
assist in conducting a criminal background check. By not providing the required information, I am
voluntarily suspending, terminating or forfeiting my opportunity for employment.

I hereby authorize any representative of the Idaho Department of Correction (IDOC) or POST
Council agent bearing this release, or copy of this release, within one-year of its date, to obtain any
or all records and information concerning myself regardless of whether the records and information
are of a confidential nature. The release of files/records and information may include, but are not
limited to, arrest records, training files, criminal files, employment records, personnel files,
disciplinary records and/or performance evaluations.

I understand that any information obtained in a personal and employment history background
investigation will be considered in determining my qualifications and suitability for employment with
IDOC. I also understand that any person, partnership, association, organization, or government
agency, including their employees who provide information concerning me, will not be liable for
providing accurate records or information.

Therefore, I release all persons and parties from all claims, damages and liabilities that may result
from providing the information requested by an authorized agent from IDOC.

Applicant/Employee:

Print full name:

Sign full name:

Social Security number: - -

Date of Birth: / /

Position applying for:

Current Residence Address

Telephone Number ( )

Date: / /

Witness – Print Full Name

Signature (Witness must be an adult, over the age of 18 that is not that applicant)

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Appendix A Background Investigation Questionnaire (BIQ)
Last Updated 06/14/2018
IDAHO DEPARTMENT OF CORRECTION
BACKGROUND INVESTIGATION QUESTIONNAIRE

Please read and answer all questions below. Please print. Be accurate and complete.
All answers are subject to verification. Use black or blue ink.

Personal Information
Last Name:

First Name:

Middle Name:
E-mail Addresses:

List OTHER names: ie; nicknames, and when applicable, maiden name that you are using or have used or been known
by in the past. Also, please list the time periods that the names were used:
OTHER NAME(s) USED
(First, Middle, Last) Nicknames, AKA’s, Maiden Name (if applicable)
From
Mo./Yr.
To
Mo./Yr.
1.
2.
3.
4.
List your CURRENT home address:
Address City State Zip Code

Primary Phone Number: ( ) Alternate Phone Number: ( )
List your mailing address or other point of contact if it is different from your home address:
Mailing Address

City State Zip Code

Please answer the following questions regarding your citizenship:

Are you legally authorized to work in the United States?

If you are applying for a security position (Correctional Officer, Food Service Officer, or Probation
and Parole Officer) you must be a United States Citizen or be able to obtain citizenship within 6
months of your hire date. (IDAPA Rule 11.11.04.032)

Yes No

The personal information you provide below is required for verification in conducting the criminal background check:
Date of Birth Place of Birth Social Security Number
Mo. Day Year City State

Current Driver’s License #
State Issued:
Other states that you have had a Driver’s License in:

Height

Weight Hair Color Eye Color
Gender Race (Check Below)
Male Female African American Asian Caucasian Hispanic
Native American Other (Please Define):

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Appendix A Background Investigation Questionnaire (BIQ)
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Former Residences – Last 10 Years

Please list your residences for the past 10 years in chronological order. There should not be any gaps in residency
dates. If necessary, attach additional page.

Address

City

State
From
Mo./Yr.
To
Mo./Yr.

List all states you have ever lived in:
Education

I completed high school.
I did not complete high school.
I passed the G.E.D. (General Educational Development) test: _____________________________________ Mo./Yr. Obtained City/State Obtained
Beginning with high school, list below all the higher education schools that you have attended:
Name of School City/State

Major

From (Mo/Yr) To (Mo/Yr) Credits Earned Degree Earned

Name of School City/State

Major

From (Mo/Yr) To (Mo/Yr) Credits Earned Degree Earned

Name of School City/State

Major

From (Mo/Yr) To (Mo/Yr) Credits Earned Degree Earned

Name of School City/State

Major

From (Mo/Yr) To (Mo/Yr) Credits Earned Degree Earned

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Appendix A Background Investigation Questionnaire (BIQ)
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Licensing/Certification
Do you currently hold, or have you ever possessed a professional license or certification?
If Yes please list below and attach copy of license/certificate
Yes No
Name of License/Certification State of Issuance Date Issued Date Expired

Has a professional licensing or certification board ever disciplined you, or have you ever
had your license or certification revoked?
Yes No
If Yes, please explain below. Include date, reason, and outcome. (If more room is needed attach additional page)

Military
Are you currently, or have you ever served in the U.S. military or National Guard? (If Yes,
please provide a copy of DD-214, or NGB-22)
Yes No
Branch of Service/Reserve Branch Date of
Entry
Date of
Discharge Type of Discharge

If currently active, list your unit and location.

Have you ever received any formal or informal discipline? If Yes, please explain below. Include date, reason, and
outcome. (If more room is needed attach additional page)

Qualifications/Related Training
Please list any qualifications or training related to the position you are applying for.

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Appendix A Background Investigation Questionnaire (BIQ)
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Employment History – 10 Years
• Beginning with your most recent employment, chronologically list your past ten (10) years of employment.
• List all periods of time you were unemployed and state what you were doing during that time. You must
account for all time during the past ten years.
• Personal Reasons and “Will explain in person” are not acceptable reasons for leaving employment.
Please provide a detailed explanation in the Reason for leaving box.
• Please attach additional pages if more room is needed.

Dates of Employment Business Name Business Address
From (Mo/Yr) – To (Mo/Yr)

Full-time Part-time Volunteer Seasonal Student Military Other
Job Title:

Job Duties: Telephone Number:
Supervisor’s Name:

Can we contact your employer? If “no,” please explain: Yes

Reason for Leaving:

Were you unemployed between these jobs? Yes No If “Yes” explain why below (i.e. school, between jobs, travel, etc.)

Dates of Employment Business Name Business Address
From (Mo/Yr) – To (Mo/Yr)

Full-time Part-time Volunteer Seasonal Student Military Other
Job Title:

Job Duties: Telephone Number:
Supervisor’s Name:

Can we contact your employer? If “no,” please explain: Yes

Reason for Leaving:

Were you unemployed between these jobs? Yes No If “Yes” explain why below (i.e. school, between jobs, travel, etc.)

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Appendix A Background Investigation Questionnaire (BIQ)
Last Updated 06/14/2018
Dates of Employment Business Name Business Address
From (Mo/Yr) – To (Mo/Yr)

Full-time Part-time Volunteer Seasonal Student Military Other
Job Title:

Job Duties: Telephone Number:
Supervisor’s Name:

Can we contact your employer? If “no,” please explain: Yes

Reason for Leaving:

Were you unemployed between these jobs? Yes No If “Yes” explain why below (i.e. school, between jobs, travel, etc.)

Dates of Employment Business Name Business Address
From (Mo/Yr) – To (Mo/Yr)

Full-time Part-time Volunteer Seasonal Student Military Other
Job Title:

Job Duties: Telephone Number:
Supervisor’s Name:

Can we contact your employer? If “no,” please explain: Yes

Reason for Leaving:

Were you unemployed between these jobs? Yes No If “Yes” explain why below (i.e. school, between jobs, travel, etc.)

Dates of Employment Business Name Business Address
From (Mo/Yr) – To (Mo/Yr)

Full-time Part-time Volunteer Seasonal Student Military Other
Job Title:

Job Duties: Telephone Number:
Supervisor’s Name:

Can we contact your employer? If “no,” please explain: Yes

Reason for Leaving:

Were you unemployed between these jobs? Yes No If “Yes” explain why below (i.e. school, between jobs, travel, etc.)

If more room is needed print off additional page 7’s until your 10 year work history is
complete.

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Appendix A Background Investigation Questionnaire (BIQ)
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Terminations
Have you ever been fired, laid-off, failed to complete probation, asked to resign, or
resigned pending investigation from employment?

Yes No
If you answered “yes” to the question above, please provide an explanation below:
Mo./Yr. Name of Employer Please provide a detailed explanation regarding the termination:

If more room is needed for explanation please attach additional page
Law Enforcement Employment
Have you been previously employed with the Idaho Department of Correction or any
other law enforcement agency? (Corrections, Police, Sheriff, etc.)

Yes No
Have you ever applied with the Idaho Department of Correction or any other law
enforcement agency? (Corrections, Police, Sheriff, etc.)
Yes No
Have you ever attended a POST Academy? Yes No
If you answered “yes” to any of the questions above, please complete the requested information below:

Job Title/Position

Agency

City, State
Reason for Leaving/Outcome of
application or academy
From
Mo./Yr.
To
Mo./Yr.

Drug Usage

Have you ever legally or illegally tried, experimented with, possessed or bought any form of
marijuana? (This includes but is not limited to cannabis, hashish, hash oil, marijuana edibles, or
synthetic/natural THC)

Do you currently use any illegal drugs, narcotics or pills that are prohibited by the Uniform
Controlled Substances Act?

Have you ever tried, experimented with, possessed, or bought any type of illegal drug, narcotic,
or controlled substance?

Have you ever sold, distributed, or transported an illegal drug, narcotic, or controlled substance?

Have you ever participated in the cultivation or production of an illegal drug, narcotic, or
controlled substance?

Have you ever used a prescription medication that was not currently prescribed to you at the
time? (If yes, list on following page)

To your knowledge, does any of your present circle of friends or acquaintances use any illegal
drugs, narcotics, or controlled substances?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

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Appendix A Background Investigation Questionnaire (BIQ)
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Drug Usage (cont’d)
List all drugs or narcotics you have ever used and/or experimented with. Do not list prescription
medications that were prescribed to you.
Type of Drug or Narcotic First Used
Mo./Yr.
Last Used
Mo./Yr.
Total # of Times
Used in Lifetime:
Bought
(Yes/No)
Sold
(Yes/No)

Arrests/Convictions
• It is your responsibility to know your complete criminal and traffic history.
• A criminal record in itself does not necessarily disqualify you from employment. However, omitting or
falsifying information is reason for disqualification or termination once employed.
• You must list all criminal charges regardless if they were dismissed, sealed, expunged, withheld,
vacated, or amended.
• If you are unsure of your criminal history you can find most Idaho cases online at www.idcourts.us, for
other states, most records can be obtained through county court houses either online or in person.
• Severity of crimes can vary from state to state. While traffic tickets are infractions in Idaho, the same
infraction may be a misdemeanor in another state.
As an adult or juvenile have you ever been arrested, cited, or charged with a FELONY offense;
regardless of whether the charge was dropped, dismissed, plea bargained, or you were found
not guilty?

As an adult or juvenile have you ever been found guilty of a FELONY? (This includes diversion
treatments, bond forfeitures, and withheld judgments)

As an adult or juvenile have you ever been arrested, cited, or charged with a MISDEMEANOR
offense; regardless of whether the charge was dropped, dismissed, plea bargained, or you were
found not guilty?

As an adult or juvenile have you ever been found guilty of a MISDEMEANOR? (This includes
diversion treatments, bond forfeitures, and withheld judgments)

As an adult or juvenile have you ever had a warrant or issued for your arrest?

As an adult or juvenile have you ever had a no contact order served against you?

As an adult or juvenile have you ever engaged in sexual abuse in a prison, jail, lockup,
community confinement facility, juvenile facility, or other institution?

As an adult or juvenile have you ever been convicted criminally of engaging or attempting to
engage in sexual activity in the community facilitated by force, overt or implied threats of force,
coercion, or if the victim did not consent or was unable to consent or refuse?

As an adult or juvenile have you ever been civilly or administratively adjudicated to have
engaged in the activity described in the question above?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

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Appendix A Background Investigation Questionnaire (BIQ)
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If you answered yes to any of the questions on page 9 please list all felony and
misdemeanor charges below. Include warrants and traffic misdemeanors in this section.
Date (Mo/Yr): Charge/Crime: Felony No Contact Order
Misdemeanor Warrant
Disposition (Guilty, Dismissed, etc.): City, County, State: Arresting agency:
Explain the circumstances of the charge listed above.

Date (Mo/Yr): Charge/Crime: Felony No Contact Order
Misdemeanor Warrant
Disposition (Guilty, Dismissed, etc.): City, County, State: Arresting agency:
Explain the circumstances of the charge listed above.

Date (Mo/Yr): Charge/Crime: Felony No Contact Order
Misdemeanor Warrant
Disposition (Guilty, Dismissed, etc.): City, County, State: Arresting agency:
Explain the circumstances of the charge listed above.

Date (Mo/Yr): Charge/Crime: Felony No Contact Order
Misdemeanor Warrant
Disposition (Guilty, Dismissed, etc.): City, County, State: Arresting agency:
Explain the circumstances of the charge listed above.

If more room is needed print off additional page 10’s until your criminal history is complete.

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Appendix A Background Investigation Questionnaire (BIQ)
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Traffic History – Last 5 Years
List all traffic citations and infractions from the last 5 years below even if they were dismissed, dropped, bond
forfeited, or amended.
Date (Mo/Yr): Charge:
Disposition (Guilty, Dismissed, etc.): City, County, State: Ticketing agency:

Date (Mo/Yr): Charge:
Disposition (Guilty, Dismissed, etc.): City, County, State: Ticketing agency:

Date (Mo/Yr): Charge:
Disposition (Guilty, Dismissed, etc.): City, County, State: Ticketing agency:

Date (Mo/Yr): Charge:
Disposition (Guilty, Dismissed, etc.): City, County, State: Ticketing agency:

Date (Mo/Yr): Charge:
Disposition (Guilty, Dismissed, etc.): City, County, State: Ticketing agency:

Date (Mo/Yr): Charge:
Disposition (Guilty, Dismissed, etc.): City, County, State: Ticketing agency:
If more room is needed print off additional page 11’s until your traffic history is complete.

Driver’s License Suspensions
Has your driver’s license EVER been suspended? YES NO If YES Please explain below.
From (Mo/Yr) – To (Mo/Yr) State Reason

If more room is needed print off additional page 11’s until your suspension history is
complete.

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Appendix A Background Investigation Questionnaire (BIQ)
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Relatives, Friends and Acquaintances in the System
This includes but is not limited to: Relatives such as child, parent, brother, sister, grandparent, aunt, uncle, niece, first cousin,
fiancé, or legal spouse, common-law spouse, or “significant other”, friends, acquaintances, someone with whom you have
previously had a relationship. Also, relatives include your in-laws and/or individuals related to your “significant other”.

Do you know anyone who is currently, or has ever been incarcerated in any county facility, state institution,
or federal prison?

Do you know anyone who is currently, or has ever been on probation or parole?

Have you ever lived with anyone who is currently, or has ever been incarcerated in any county facility, state
institution, or federal prison?

Have you ever lived with anyone who is currently, or has ever been on probation or parole?

Have you ever applied to become a visitor for an offender incarcerated in any county facility, state
institution, or federal prison?

Are you currently visiting an offender incarcerated in any county facility, state institution, or federal prison?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If you answered “Yes” to any question above please fill out the section below

Full name of relative, friend, or acquaintance: Relationship to you: Crime:
Currently incarcerated?

Yes No

From (Mo/Yr) – To (Mo/Yr)
On Probation/Parole?

Yes No

From (Mo/Yr) – To (Mo/Yr)
Location of institution or probation/parole district:
Name of institution or probation/parole officer:

Full name of relative, friend, or acquaintance: Relationship to you: Crime:
Currently incarcerated?

Yes No

From (Mo/Yr) – To (Mo/Yr)
On Probation/Parole?

Yes No

From (Mo/Yr) – To (Mo/Yr)
Location of institution or probation/parole district:
Name of institution or probation/parole officer:

Full name of relative, friend, or acquaintance: Relationship to you: Crime:
Currently incarcerated?

Yes No

From (Mo/Yr) – To (Mo/Yr)
On Probation/Parole?

Yes No

From (Mo/Yr) – To (Mo/Yr)
Location of institution or probation/parole district:
Name of institution or probation/parole officer:

If more room is needed print off additional page 12’s until your relationship history is
complete.

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Appendix A Background Investigation Questionnaire (BIQ)
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For all friends, relatives, and acquaintances listed on the previous page complete the following
questions for each.
PLEASE USE A SEPARATE PAGE FOR EACH INDIVIDUAL LISTED.

RELATIVE(s), FRIENDS, ACQUAINTENCES, ETC.
If not a family member, how did you meet the individual?
How long has it been since you had contact with this individual? What type of contact did you have with the
individual?(i.e. phone, email, letter, face to face)
Have you ever visited or had personal contact with this individual? If so, please explain

Are you currently or have you ever lived with this individual? If so, when, and for how long?
Please give a detailed history of your relationship with the individual.

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Appendix A Background Investigation Questionnaire (BIQ)
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Source
How did you find out about applying for employment with the Dept of Correction?

Division of Human Resources Friend Internet Job Fair

Job Service Radio Television Job Announcement

Other ______________________________________________________________

CERTIFICATION OF BACKGROUND ANSWERS
Please read and sign below

Department’s Statement
The statements and answers that you provided in this background questionnaire are subject to
verification. Any discrepancies, misstatements, omissions and/or falsifications that you made,
may disqualify you from consideration for employment, or may result in your dismissal from
employment with the Idaho Department of Correction (IDOC).

Applicant/Employee Statement of Understanding
I voluntarily agreed to provide this completed background questionnaire for the purpose of
conducting a background check prior to a conditional offer of employment.
I understand that the background questionnaire must be fully completed and no information left
out. If the form is partially completed, I may not be considered for employment.

Applicant/Employee Statement of Certification
I certify that all of my answers in this questionnaire are true and complete. I understand that any
discrepancies, misstatements, omissions and/or falsifications will subject me to disqualification
from employment, disciplinary actions during my employment, and/or dismissal from employment
with IDOC.

Applicant/Employee Signature:

Print full name:

Sign full name:

Date: / /