Sex Offender Chaperone Background Investigation Questionnaire

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

Offender’s Information
Offender’s name: IDOC #:
Proposed Chaperone’s Personal Information
Print or type your full legal name:
Last First Middle
List all other names you go by (i.e., nicknames, maiden, other married)
What is your relationship to the offender?
Do you know what crime(s) the offender committed? If yes, what is/are they?
List your current home address
Street City State Zip
List your current phone numbers
Home Cell Other
Provide your mailing address (if different from home address)
Street City State Zip
Are you a citizen of the United States? Yes  No  If no, answer the next questions.
Are you a permanent resident alien who is eligible for and has applied for citizenship? Yes  No 
Have you obtained permission from INS to work in the United States? Yes  No 
Note: The following information you provide is required for verification in conducting the criminal background check:
Date of Birth / / Place of Birth
City State
Social Security Number / / Driver’s license # State
Height Weight Hair Color Eye Color
Gender Male  Female  Race
Employer’s Name and Address
Drug or alcohol use? Yes  No  If yes, please list
Any felony offenses? Yes  No  If yes, please list
Any misdemeanor offenses? Yes  No  If yes, please list

Certification of Background Investigation Questionnaire Answers

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

Proposed Chaperone’s Statement of Understanding
I voluntarily agreed to provide this completed background questionnaire for the purpose of conducting a background check for consideration as a chaperone. I understand that the background
investigation questionnaire must be fully completed and no information left out. If the form is partially completed, I may not be considered as a chaperone.

Proposed Chaperone’s 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 being eligible as a chaperone with IDOC.

Proposed Chaperone’s Printed Name

Proposed Chaperone’s Signature Date