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Obnoxious questionniare for public servants
Public Servants Questionaire
Name of Public Servant_____________________________________________________
Resident Address __________________________________________________________
City__________________ State____ Zip______________________
Phone(____)____-_________
Name of government bureau or agency by which public servant is employeed
___________________________________________________________________________
Mailing Address____________________________________________________________
City___________________ State____ Zip_____________________
Phone(____)____-________
Length of time employeed by this agency Years-____________Months-__________
Job Title or Description___________________________________________________
Name of Immediate supervisor_______________________________________________
Does Public servant have proof of Identity (Y,N)
Nature of Proof ___________________________________________________________
State fully the purposes for which any information is being gathered and the
purpose of this investigation or contact ___________________________________
____________________________________________________________________________
____________________________________________________________________________
Name of agency and/or person requesting this investigation or call be made
----------------------------------------------------------------------------
Is this investigation: (A / B) where
A=}General (a blanket investigation in which a number of persons are
involved because of geography, type of business, politics
sex, income, etc.)
B=} Special (any investigation of an individual in which others are
not involved.)
If answer is B-}Special,state the identity of the person being investigated
____________________________________________________________________________
If answer is A-}General, state the nature of the selection process that
resulted in our inclusion in this investigation.
____________________________________________________________________________
Page 1 of 2
Public Servants Signature denoting that he or she has read this
page of the PUBLIC SERVANTS QUESTIONAIRE
__________________________________________________________________
Was a private citizen resposible for initiating this investigation? (Y\N)
If Yes then state his or her name and the date that citizen suggested this
investigation and to what agency.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Are the answers to the questions or the information you are requesting
required by law or voluntary.(circle one)
If this information is required by law:
1: Provide full citations to the relevant statutes, executive orders,
or regulations for such compulsory response and attach copies of
such laws hereto.
2: State the penalties ond or consequences should we refuse to comply.
Are answers to all questions legally required or only some of them?
(check one) ( ) ALL ( ) SOME
If only some please indicate which questions are voluntary.
Will the information obtained as a result of this investigation be held
"CONFIDENTIAL" by the public sevants agency or will any other public or
private agency have access to such information
_____________________________________________________________________________
If shared attach a list of all potential recipiants of these reports (or
sections thereof) and the legal authority for such sharing of information
If we want to inspect the record compiled about us on the basis of this
investigation will we be entitled to do so. (Yes, No)
If "No" attach explination , if "Yes" attach the detailed location of the
files, Access procedures,procedure for contesting the accuracy and/or
completness of said records, and the name and address of the agency official
in charge of such procedures.
>->-WARNING-<-<
You are hereby advised of the following Federal Criminal Law:
"If two or more persons conspire to injure, oppress, threaten or intimidate
any citizen in the exercise or enjoyment of any right secured to him by
the Constitution or the laws of the United States, or because of his having
so exersised the same; or if to or more persons go in diguise on the highway
,or on the premises of another, with the intent to prevent or hinder his
free exercise or enjoyment of any right or privilege so served- they shall
be fined not more than $10,000 or imprisoned not more than ten years or both
; and if death results they shall be subject to imprisonment for any term
of years or for life"- U.S.C. Title 18, Sec 241
AFFIRMATION BY PUBLIC SERVANT
I hereby swear and affirm that the answers I have given to the foregoing
questions are complete and correct in every particular and that I have read
this questionare in its entirety as shown by my signature on each page.
_________________________________________________ ______/_____/_____
(Public Servant) (Date)
Page 2 of 2
}Please see attached Private Citizens Report{
PRIVATE CITIZENS REPORT
Has the Public servant been courteous and cooperative?_______________________
_____________________________________________________________________________
Has he or she made any threats?______________________________________________
If so what are the nature of those threats___________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Were there any witnesses to this Public Servants behavior (Yes,No)
If yes please have each of them attach a complete a copy of this form and
attach it for later review.
AFFIRMATION BY PRIVATE CITIZEN
I hereby swear and affirm that I have answered the questions on this form
completely and correctly to the best of my ability.
___________________________________________ ________/________/______
(Name) (Date)
___________________________________________
(Address)
________________________,_______,__________
(City) (State) (ZIP)
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