EMPLOYERS STATEMENT REQUIRED BY THE EMPLOYEE
POLYGRAPH PROTECTION ACT OF 1988 (EPPA)
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.
EMPLOYERS ECONOMIC LOSS OR INJURY: (DESCRIBE SPECIFICALLY)
The employer is requesting that the above mentioned person take the test because (State
employees ACCESS to loss under investigationbe 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 employees signature, not including weekends.)
If test is to be conducted at a site other than LaCostas office please strike through our address and write in the correct address.
THIS STATEMENT MUST BE RETAINED BY THE EMPLOYER FOR A PERIOD OF AT LEAST THREE YEARS.
EMPLOYERS SIGNATURE AND DATE__________________________________
Must be signed by an agent of the company and not a polygraph examiner.
EMPLOYEES SIGNATURE AND DATE__________________________________
By signing you acknowledge you have been given a copy of this Statement.
INFORMATION AND NOTIFICATIONS REQUIRED UNDER
THE EMPLOYEE POLYGRAPH PROTECTION ACT
OF 1988 (EPPA)
Phone (___) __________________ Drivers License # _____________________
Date of Birth ____________________ Social Security # _____________________
Business Address ____________________________________________________
Phone (___) __________________ Fax (___ )_________________________
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.
NOTICE OF POLYGRAPH EXAMINEES RIGHTS
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 others knowledge, to record electronically the entire examination.
POLYGRAPH EXAMINERS NOTICE TO EXAMINEE REGARDING THE TEST
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.
Examiners Signature_______________________________ Date __________________
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.
Employers 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.
Examinees Signature_______________________________ Date __________________
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