Instructions: Please provide the information requested ...



SACRAMENTO COUNTY SHERIFF’S DEPARTMENT

PERSONAL HISTORY STATEMENT

LAW ENFORCEMENT EXPERIENCE

SUPPLEMENTARY QUESTIONNAIRE

(Rev. 1/2015)

PRE-EMPLOYMENT INVESTIGATION INSTRUCTIONS

WAIVER GRANTING DISCLOSURE OF CONFIDENTIAL RECORDS

Included in this supplementary questionnaire is a “Waiver Granting Disclosure of Confidential Peace Officer Personnel Records” which authorizes Sheriff's Department investigators to access your confidential personnel records. If you have been employed as a peace officer (including temporary, part-time, and volunteer employment) at more than one agency, you will need to sign, have notarized, and submit one waiver form for each such agency. Notary service is available at the Pre-Employment Investigation Unit free of charge. Please call in advance to ensure that a notary will be available.

ADVISEMENT TO PEACE OFFICERS SEEKING LATERAL PLACEMENT

Also included is a one-page advisement for applicants who are currently employed as a peace officer (including temporary, part-time, and volunteer employment). If you are currently employed as a peace officer, please read the advisement, fill-out the bottom portion, and submit it with your completed supplementary questionnaire.

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SACRAMENTO COUNTY SHERIFF’S DEPARTMENT

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WAIVER GRANTING DISCLOSURE OF CONFIDENTIAL

PEACE OFFICER PERSONNEL RECORDS

TO THE CUSTODIAN OF PEACE OFFICER RECORDS, __________________________________

Department Name

I, the undersigned, am an applicant for employment with the Sacramento County Sheriff’s Department. I understand that my prospective employer, its agents and/or assigns, cannot make a determination regarding my fitness for this position without a full and unrestricted disclosure of any and all information relative to my performance as a peace officer, including personnel records or other information in your possession which may be deemed confidential pursuant to Government Code 6254 (c), Penal Code 832.5 and 832.7, or which may be protected from disclosure under Evidence Code 1043 and 1045, including but not limited to: records of application, appraisal, counseling, attendance, payroll, complaints, the investigation or findings of misconduct, discipline, criminal history, commendation, promotion, training and education, experience, professional certification, character reference, or personal data; and records or information which may, as a result of an agreement between the undersigned and the Chief of Police or Sheriff or Department/Agency Head, have been sealed.

I herby acknowledge that a legal privilege exists concerning these records, that I am waiving that privilege for this specific purpose, and I hereby acknowledge that the Department and its Custodian of Records has been or will be served with my authorized, knowing and voluntary request for disclosure of my confidential peace officer personnel records within any period prior to the expiration date noted below. I have been offered a copy of this waiver and shall not require any additional notification thereof. This waiver is specifically granted to determine the undersigned’s eligibility and qualifications for employment with the Sacramento County Sheriff’s Department.

Therefore, I direct you to release the information described above to the bearer of this form, and I knowingly and voluntarily exonerate, release and discharge you, the department or agency named above, any agency of any city, county, state or of the United States government, their employees, officers, agents and assigns from any liability, claim or damages, now or in the future, whether in law or in equity, on behalf of myself, my agents, heirs or assigns, for granting disclosure of my confidential peace officer personnel records at my own request for employment purposes. _______________________________________________________________________________________

State of __________________________________}, County of _________________________________}

On ____________________ before me, __________________________, Notary Public, personally appeared

____________________________________________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the Stated of California that the foregoing paragraph is true and correct.

Affiant______Produced ID______ ___________________________________

Signature

____________________________ ___________________________________

Type of ID Notary’s Signature

THIS FORM MUST BE NOTARIZED

EXPIRATION IS ONE YEAR FROM THE SIGNATURE DATE SEAL

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

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SACRAMENTO COUNTY SHERIFF’S DEPARTMENT

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ADVISEMENT TO PEACE OFFICERS SEEKING LATERAL PLACEMENT

California Government Code 1031 prohibits the employment of persons who are not of good moral character or who are not fit to serve as peace officers. This legal prohibition applies equally to persons seeking employment as peace officers, as well as to persons already employed as peace officers seeking appointment in another jurisdiction.

STATEMENT

You will undergo a rigorous in-depth background investigation as a result of your application for this position. In the event that your background investigation for this position should uncover information that you have, or are suspected of having or have been engaged in illegal activities while employed as a peace officer, this information will likely bar you from further consideration from this position. Further, in the event that this illegal activity occurred during the time of your present employment as a peace officer, or if this background should uncover information which raises questions about your fitness to continue to serve as a peace officer, this information may be transmitted to your present peace officer employer for their independent investigation.

CERTIFICATION

I certify that I have read this advisement, understand its implications and have received a copy of it.

Dated: _________________ ___________________________________________

Signature of Applicant

___________________________________________

Applicant’s Printed Name

INSTRUCTIONS: Please provide the information requested on this page as it pertains to your most recent employment as a peace officer. Write “N/A” if a question is not applicable to you. If more space is needed to answer any question, please write “See Attachment” and type your response on a separate sheet of paper. Include item number on each attached response. Please ensure that this employment is also reflected in the EMPLOYMENT section of your Personal History Statement.

|Last Name First Name Middle Name |

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|                  |

|Agency Name: |

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|      |

|1.3 With regard to the above named agency, what is your current employment status? Check all that apply. |

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|On probation Other (describe): |

|On a leave of absence       |

|On administrative leave |

|Working full-time |

|1.4 With regard to your most recent assignment within the above named agency, please provide the following information: |

| |

|Job Title:       |

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|Current Work Unit:       Date Assigned:       |

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|Duties description:       |

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|First line supervisor(s):       Phone #:       |

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|Second line supervisor:       Phone #:       |

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|Third line supervisor:       Phone #:       |

|1.5 In the spaces below, please list all your assignments within your agency for the past sixty (60) months. Include special and/or temporary assignments, e.g., SWAT,|

|honor guard, reserve officer coordinator, etc. |

|Dates |Assignment (Division, Bureau, Detail, etc.) |Immediate Supervisor & |

|Mo/Yr to Mo/Yr | |Current phone number |

| |      |      |(   )    -     |

|      | | | |

| |      |      |(   )    -     |

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| |      |      |(   )    -     |

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| |      |      |(   )    -     |

|      | | | |

|2.1 Please explain why you want to leave or why you left the agency named on page S1? |

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|      |

|2.2 Please explain why you have applied with the Sacramento Sheriff’s Department. |

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|      |

|If you are hired, what are your aspirations within the Sacramento Sheriff’s Department? For example, are there any particular job assignments and/or rank that you hope |

|to attain? |

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|Please answer the remaining questions in this questionnaire as they pertain to ALL law enforcement agencies where you have been employed. For each “Yes” response to the|

|following questions, please provide the item number and details in the space below. If you have worked for more than one law enforcement agency, also include the agency|

|to which your answer pertains. |

|3.1 Have you ever been the subject of an internal investigation? If “Yes”, list each instance. Include date, allegation(s), disposition, | Yes | No |

|and disciplinary action, if any. | | |

|3.2 Have you ever been the subject of a disciplinary action? If “Yes”, please list each instance. Include date, cause, and supervisor(s) | Yes | No |

|involved. | | |

|3.3 Have you ever been counseled or verbally reprimanded for unacceptable performance or conduct? If “Yes”, please list each instance. | Yes | No |

|Include date, cause, and supervisor(s) involved. | | |

|3.4 Have you ever been directed to attend training to correct a performance deficiency? If “Yes”, please list each instance. Include date, | Yes | No |

|type of training, and deficiency. | | |

|3.5 Have you ever been reassigned for reasons relating to substandard performance, unacceptable conduct, or under any other adverse | Yes | No |

|circumstance? If “Yes”, please list each instance. Include date, circumstances, and supervisor(s) involved. | | |

|Item # and details: |

| |

|      |

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|These questions pertain to all law enforcement agencies where you have been employed. For each “Yes” response to the following questions, please provide the item number|

|and details in the space below. |

|4.1 Have you ever been involved in a shooting incident? If “Yes”, please list each incident. Include date, circumstances, and findings of | Yes | No |

|the shooting investigation. | | |

|4.2 Have you ever fired your weapon, either on or off-duty, other than on the firing range? If “Yes”, please list each incident. | Yes | No |

|4.3 Have you had any on-duty traffic accidents? If “Yes”, please list each accident. Include date, circumstances, and disposition. | Yes | No |

|4.4 Have you ever failed to book evidence and/or property that you were responsible for? If “Yes”, please give details of each incident. | Yes | No |

|Item # and details: |

| |

|      |

| |

|These questions pertain to all law enforcement agencies where you have been employed. For each “Yes” response to the following questions, please provide the item number|

|and details in the space below. |

|5.1 Have you ever intentionally made a false statement in or omitted significant information from a police or other official report? If | Yes | No |

|“Yes”, please provide details. | | |

|5.2 Have you ever given false testimony in court, administrative hearing, or other official proceeding? If “Yes”, please provide details | Yes | No |

|including date and nature of testimony. | | |

|5.3 Have you ever given false information during any official criminal or administrative inquiry or investigation? If “Yes”, please provide | Yes | No |

|details including date, description of inquiry or investigation, and a description of the false information. | | |

|5.4 Is there anyone in any law enforcement agency where you have been employed who might not recommend you for the position? If “Yes”, | Yes | No |

|please provide name(s) and explanation. | | |

|5.5 Is there anyone in any law enforcement agency where you have been employed who might not give an objective assessment of your | Yes | No |

|qualifications? If “Yes”, please provide name(s) and explanation. | | |

|Item # and details: |

| |

|      |

|3.16 Is there anything else regarding your employment as a peace officer that you believe is significant to this pre-employment investigation? No |

|Yes - Please provide details. |

| |

|      |

|3.1 If you are given a job offer, will your acceptance be contingent on the job assignment that you will be given or on any other specific condition of employment? |

|No Yes - Please explain. |

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|      |

|Please check each type of document that applies to you and include a copy with the documents that you have been requested to submit. If you do not have a copy, please |

|obtain one from your agency. |

| |

|Letters of commendation/appreciation |

|Performance evaluations written in the past sixty (60) months |

|Letters of reprimand |

|Documented counseling |

|Other documents that reflect performance and/or conduct – describe: |

|Please check each certificate that applies to you and include a copy with the other documents that you have been requested to submit. |

| |

|Basic academy certificate |

|Basic POST certificate |

|Intermediate POST certificate |

|Advanced POST certificate |

|Training certificates of completion – job related |

|Other special certification(s) – describe: |

|I hereby certify that all statements made in this personal history statement are true and complete and I understand that any misstatement or omission of material fact |

|may subject me to disqualification or removal from the employment certification list. |

|Signature in full |Date completed |

| | |

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IMPORTANT

This supplementary questionnaire is a permanent record and part of the Personal History Statement. All information must be typewritten. Handwritten SìTìUìVìZì[ìiìjìkìlìjíkíyízí{í|í€í?í?í?í‘í’í­íÂíÈíåíFîGîUîVîWîXî\î]îkîlîëÝÓÉÝÓµÝÓÉÝÓ¡ÝÓÉÝÓ?ÝÓɃɃÉÝÓoÝÓÉÝÓ['[?]?jIV[pic]h³Nähx±CJOJ[?]QJ[?]U[pic]'[?]?jÓU[pic]or incomplete questionnaires will not be accepted. Submit the completed original questionnaire to the Sacramento Sheriff’s Department, Pre-Employment Investigations Unit, 711 G Street, Sacramento, CA 95814 – OR – P.O. Box 988, Sacramento, CA 95812-0988. Copies will not be accepted.

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