Public Servant Questionnaire
1a. Name and title of public servant:
1b. Residence address:
1c. City, State, Zip Code:
2a .Full name of government department, bureau, or agency by which public servant is employed
2b. Mailing address:
2c. City, State, Zip Code:
2d. Telephone number:
3a. Supervisor’s name and title:
3b. Mailing address:
3c. City, State, Zip Code:
3d. Telephone number:
4. Will public servant uphold the PRIVACY and FREEDOM OF INFORMATION ACTS? Yes No (circle answer)
5a. Will public servant furnish proof of identity? Yes No (circle answer)
5b. Nature of proof provided? I.D./Employee/Badge No.
5c. Other (List details):
6. Will public servant furnish a copy of the laws or regulations which authorize this investigation prior to proceeding? Yes No (circle answer)
7. Are the questions to be asked based upon a specific law or regulation? Yes No (circle answer)
8. Will the public servant read aloud the portion of the law authorizing the questions he/she will ask ? Yes No (circle answer)
9. Are/will answers given be used as/in a discovery process? Yes No (circle answer)
10a. Are the answers voluntary or mandatory? Voluntary Mandatory (circle answer)
10b. If mandatory, list penalties for non-compliance. If voluntary, list any possible effects upon me, my real property and my personal property if I should choose to not answer any part or all of the questions.
11. What other uses may be made of this information?
12. What other agencies may have access to this information?
13a. Name and title of the person in the Government requesting/ordering this investigation:
13b. Mailing address:
13c. City, State, Zip Code:
13d. Telephone number:
14. Circle the nature of this investigation: General Special
Note: “General” means any kind of blanket investigations in which a number of persons are involved for any reason. Special means any investigation of an individual nature in which others may or may not be involved.
15. Provide complete details of the investigation or inquiry.
16a. Have you consulted, questioned, interviewed, or received information from a third party, relative to this investigation? Yes No (circle answer)
16b. If yes, list the identity of all such third parties including name, mailing address and telephone number.
17a. Do you anticipate civil or criminal action to be pursued based upon any of the information that you seek? Yes No (circle answer)
17b1. If yes, which action: Civil Criminal (circle answer)
17b2. If civil, list possible claims:
17b3. If criminal, list possible charges and penalties:
18a. Is there a file of records, information or correspondence relating to me being maintained by this agency? Yes No (circle answer)
18b1. If yes, will public servant provide me access to the records, information or correspondence for the purpose of my reviewing them for accuracy prior to commencement of questioning? Yes No (circle answer)
18b2. If yes, provide details of how and when access will be provided. If no, list reasons for denial of access.
19a. Is the public servant and/or public servant's department, bureau, or agency using information pertaining to me, which was supplied, by another agency or Government source? Yes No (circle answer)
19b. If yes, which agency or source? Include agency/source name, mailing address, and telephone number.
20a. Will the public servant guarantee that the information in these files will not be used by any other department other than the one by which he/she is employed? Yes No (circle answer)
20b. If no, detail reason(s) for refusal:
Signed under penalties of perjury this _________day of ___________, 20____.
Public Servant (Print Name):
Public Servant Signature:
Public Notary or Justice of the Peace
Witness (Print Name and Title):
Witness (Signature):
Witness Seal or Stamp (If applicable in jurisdiction):
