Public Psychological Services 10/29/2019

SUPPLEMENTAL PSYCHOLOGICAL HISTORY QUESTIONNAIRE FOR JOB SUITABILITY ASSESSMENT AFTER A CONDITIONAL OFFER OF EMPLOYMENT (COE) Name: SSN: Today's Date: Contact Tel No: (Day) (Eve) Please remember that the information you provide will be verified through background investigation and, in most agencies, a polygraph examination. Providing false information during the application process may be grounds for rejection during the selection process, or termination from employment if falsification is discovered later. SECTION 1A: WORK HISTORY List ALL employers for the last ten years (but not different positions for the same employer), including part-time and seasonal positions. Account for ALL time periods including school and unemployment, starting with the present. If you have had more than five (5)jobs in ten (10) years use the back of this form to provide that information. 1.) From To PRESENT Position Employer Employed Full Time Employed Part-Time School Full-Time Unemployed Other 2.) From To Position Employer Employed Full Time Employed Part-Time School Full-Time Unemployed Other Reason for Leaving: 3.) From — To Position- Employer Employed Full Time Employed Part-Time School Full-Time Unemployed Other Reason for Leaving: 4.) From To Position Employer Employed Full Time Employed Part-Time. School Full-Time Unemployed Other Reason for Leaving: 5.) From To Position Employer Employed Full Time Employed Part-Time School Full-Time Unemployed Other Reason for Leaving: If you need more space to list your job history please ask for an extra sheet of paper. (c) Law Enforcement Psychological Services, Inc. (408) 356-9696 Rev DgAAr19 Post_PsyQ Supp NY.doc 49