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EMPLOYER: ____________________________________________

ADDRESS: ____________________________________________

EMPLOYEE: ____________________________________________

ADDRESS: ____________________________________________

The employer listed above is requesting that the employee listed above submit voluntarily to

a polygraph examination to be administered in connection with an ongoing investigation

into an economic loss or injury to the business, such as theft, embezzlement,

misappropriation, act of unlawful industrial espionage or sabotage.



The employer is requesting that the above mentioned person take the test because (State

employee’s ACCESS to loss under investigation—be specific.)


The employer has a BASIS FOR REASONABLE SUSPICION that the employee could

have been involved in the incident under investigation because (be specific). ______________________________________________________________________

The employee has the right to obtain and consult with legal counsel or an employee representative before this examination.

The test will be conducted at LaCosta Data Services, Inc., 15455 Dallas Parkway, Ste. 600, Addison, TX, 75001, (972) 735-9569, at _________________________________ (Day and time of test). NOTE: Test must be at least 48 hours after employee’s signature, not including weekends.)

If test is to be conducted at a site other than LaCosta’s office please strike through our address and write in the correct address.



EMPLOYER’S SIGNATURE AND DATE__________________________________

Must be signed by an agent of the company and not a polygraph examiner.


EMPLOYEE’S SIGNATURE AND DATE__________________________________

By signing you acknowledge you have been given a copy of this Statement.





OF 1988 (EPPA)


Examinee’s Name______________________________________________________

Address ____________________________________________________________

Phone (___) __________________ Driver’s License # _____________________

Date of Birth ____________________ Social Security # _____________________

Employer’s Name______________________________________________________

Business Address ____________________________________________________

Phone (___) __________________ Fax (___ )_________________________

Contact _____________________________________________________________

Polygraph Examinations to be performed by Dianne Robinson at the offices of LaCosta Data Services, located at 15455 Dallas Parkway, Suite 600, Addison, TX, 75001 (972) 735-9569.

Date of Test ______________________

Time Test Began______________________ Time Test Ended__________ _____

If test is to be conducted at another location indicate on next line. Int.








Section 8(b) of the Employee Polygraph Protection Act of 1988 and Department of Labor regulations (29 CFR 801.22) require that you be given the following information:


The polygraph examination area (will) (will not) contain a two-way mirror, a camera, or another device through which you may be observed. Another device, such as those used in conversation or recording, (will) (will not) be used during the examination.

Both you and the employer have the right, with the other’s knowledge, to record electronically the entire examination.

You have the right to terminate the test at any time.
You have the right and will be given the opportunity to review all questions to be asked during the test.
You may not be asked questions in a manner, which degrades or needlessly intrudes.
You may not be asked any questions concerning religious beliefs or affiliations /opinions, beliefs regarding racial matters, political beliefs or affiliations, matters relating to sexual behavior, beliefs, affiliations, opinions, or lawful activities regarding unions or labor organizations.
The test may not be conducted if there is sufficient written evidence by a physician that you are suffering from a medical or psychological condition or undergoing treatment that might cause abnormal responses during the examination.
The test is not and cannot be required as a condition of employment.
The employer may not discharge, dismiss, discipline, deny employment or promotion, or otherwise discriminate against you based on the results of a polygraph test, or based on your refusal to take such a test without additional evidence which would support such action.
In connection with an ongoing investigation, the additional evidence required for an employer to take adverse action against you, including termination, may be (A) evidence that you had access to the property that is the subject of the investigation, together with (B) the evidence supporting the employer’s reasonable suspicion that you were involved in the incident or activity under investigation.
Any statement made by you before or during the test may serve as additional supporting evidence for an adverse employment action as described above and any admission of criminal conduct by you may be transmitted to an appropriate government law enforcement agency.
Information acquired from a polygraph test may be disclosed by the examiner or by the employer only to A.) to you or any other person specifically designated in writing by you to receive such information, B.) to the employer that requested the test, C.) to a court, governmental agency, arbitrator, or mediator that obtains a court order, and D.) to a U.S. Department of Labor Official when specifically designated in writing by you to receive such information.
Additionally information acquired from a polygraph test may be disclosed by the employer to an appropriate governmental agency without a court order where, and only insofar as, the information disclosed is an admission of criminal conduct.
If any of your rights or protections under the law are violated, you have the right to file a complaint with the Wage and Hour Division of the U.S. Department of Labor, or to take action in court against the employer. Employers who violate this law are liable to the affected examinee, who may recover such legal or equitable relief, as may be appropriate, including employment, reinstatement, and promotion, payment of lost wages and benefits, and reasonable costs, including attorney’s fees. The Secretary of Labor may also bring action to restrain violations of the Act, or may assess civil money penalties against the employer.
Your right under the Act may not be waived, either voluntarily or involuntarily, by contract or otherwise, except as part of a written settlement to a pending action or complaint under the act and agreed to and signed by the parties.





The examinee has the right to obtain and consult with legal counsel or an employee representative before each phase of the test, the pretest phase, the actual testing and the post-test phase.
The polygraph test is for the purpose of determining the truthfulness of the examinee’s answers to the relevant questions listed on the attached amendment.
During the polygraph test there will be A.) a pretest interview in which the polygraph examiner goes over the facts and reviews with the examinee the relevant questions to be asked on the test; B.) the test itself in which the examinee is asked the relevant questions, as well as certain other questions (including those needed for comparison purposes) while his or her physiological responses are being recorded by a polygraph instrument, and C.) a post-test interview in which the examinee is afforded a reasonable opportunity to explain and eliminate any deceptive reactions which are evident on the polygraph charts.
The polygraph instrument records the following physiological responses, breathing and respiration, blood pressure and pulse rate, and electrodermal patterns.

The State of Texas, (License # 880), has duly licensed the undersigned, Dianne Robinson, a polygraph examiner employed by LaCosta Data Services. When signing this document she warrants that she has during the pretest phase explained or caused to be explained in a language understood by the examinee, the contents of the above and foregoing compliance form to the examinee, requested him or her to sign it, and delivered a copy of the same to him or her. She also warrants that she has read to the examinee those areas in this document that are underlined.

Examiner’s Signature_______________________________ Date __________________

Dianne Robinson

The Employer warrants that he or she has read this document and has or will comply with all regulations so stated and will comply in a timely manner.

Employer’s Signature_______________________________ Date __________________

Examinee warrants that he or she has read this document, understands it and that both Examiner and Employer have complied with all regulations and that Examiner has read to me all underlined the sections of this document.

Examinee’s Signature_______________________________ Date __________________



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Last modified: Wednesday May 24, 2000.