WRITTEN EXAMINATION PRE-INVESTIGATIVE QUESTIONNAIRE

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1 WRITTEN EXAMINATION PRE-INVESTIGATIVE QUESTIONNAIRE IT IS MANDATORY THAT ALL INFORMATION REQUESTED BE SUPPLIED. EACH QUESTION MUST BE ANSWERED; LEAVE NO BLANKS. IF A QUESTION DOES NOT APPLY, ENTER DNA IN THE SPACE PROVIDED. PLEASE PRINT, LEAVE NO BLANKS. LAST NAME FIRST NAME MI STATE DRIVER S LICENSE # DATE OF BIRTH SOCIAL SECURITY NUMBER : TELEPHONE NUMBER : RESIDENCE ALTERNATE INTERVIEWER DATE

2 ADMONISHMENT The Pre-Investigative questionnaire you are about to fill out is a very important document to you. It becomes a permanent part of your file and will be reviewed several times before you are accepted for hire. It has the potential for disqualifying you. You will find questions pertaining to the use of narcotics, your driving record, thefts, etc. Not all admissions in these areas are disqualifying. For example, some use of illegal narcotics of drugs is not automatically disqualifying. It is evaluated on a case-by-case basis. However, falsifying your answers or deliberately omitting information will be cause for disqualification. As of January 1, 1990, all applicants are polygraphed prior to being accepted for hire. Therefore, it is in your best interest to be thorough and completely honest in your answers. Integrity weighs heavily in the evaluation of any applicant being considered for hire. Do you understand this admonishment? Do you have any questions about this admonishment? Yes No Yes No x Print Name Social Security No. Signature Date

3 APPLICATION AND HISTORY RECORD Please Print in Ink PERSONAL INFORMATION : DATE OF APPLICATION POSITION APPLIED FOR LEGAL LAST NAME FIRST MI SEX AGE HEIGHT WEIGHT HAIR EYES SOCIAL SECURITY NUMBER RESIDENCE ADDRESS (NO., CITY, STATE, ZIP) LIVING WITH (PARENTS, FRIEND, ALONE, OR RELATIVE) MILITARY INFORMATION : WHILE IN THE SERVICE, WERE YOU EVER THE SUBJECT OF ANY DISCIPLINARY ACTION SUCH AS: CAPTAIN S MAST, COURT MARTIAL, OFFICE HOURS, COMPANY PUNISHMENT, OR ARTICLE 15? YES ( ) NO ( ) IF YES, EXPLAIN : IF YOU RECEIVED OTHER THAN AN HONORABLE DISCHARGE, EXPLAIN : EDUCATION INFORMATION : LIST HIGH SCHOOL GRADUATED FROM OR LAST HIGH SCHOOL ATTENDED. NAME OF SCHOOL CITY AND STATE ATTENDANCE DATES CALIFORNIA PROFICIENCY TEST GRAD? FROM TO YES WHEN TAKEN FINANCIAL INFORMATION : HAVE YOU OR YOUR SPOUSE : YES NO ANY IMMEDIATE CIVIL ACTION PENDING AGAINST YOU? YES NO EVER FILED BANKRUPTCY OR BEEN DECLARED BANKRUPT? YES NO EVER BEEN DELINQUENT IN YOUR TAXES? YES NO EVER HAD A BOND REFUSED? IF THE ANSWERS TO ANY OF THE ABOVE QUESTIONS ARE YES, EXPLAIN IN DETAIL BELOW:

4 ARREST INFORMATION : EITHER AS AN ADULT OR JUVENILE, HAVE YOU EVER BEEN DETAINED FOR INVESTIGATION, NAMED AS A SUSPECT IN A POLICE REPORT, HELD ON SUSPICION, QUESTIONED, FINGERPRINTED, OR ARRESTED BY ANY LAW ENFORCEMENT AGENCY OR MILITARY AUTHORITY? YES ( ) NO ( ) DATE CHARGE ARRESTING OR DETAINING AGENCY PENALTY TRAFFIC INFORMATION : HAS YOUR DRIVER S LICENSE EVER BEEN SUSPENDED, REVOKED, OR PLACED ON PROBATION? YES ( ) NO ( ) IF YES, EXPLAIN: LIST EVERY CITATION RECEIVED FOR A MOVING OR EQUIPMENT VIOLATION IN THE PAST THREE YEARS. DATE CHARGE ARRESTING OR DETAINING AGENCY PENALTY HAVE YOU EVER BEEN INVOLVED IN A TRAFFIC ACCIDENT? YES ( ) NO ( ) IF YES, DESCRIBE EACH ACCIDENT IN A BRIEF NARRATIVE BELOW. INCLUDE DATES, LOCATIONS, POLICE AGENCY INVOLVED, AND WHETHER OR NOT YOU RECEIVED A CITATION.

5 PRE-INVESTIGATIVE QUESTIONNAIRE Read and answer the following questions carefully and honestly. Answers are subject to verification by a polygraph examination. A yes answer is not in and of itself grounds for disqualification whereas an untruthful response will be. CRIMINAL AND ARREST INFORMATION 1. Have you ever committed any of the following acts? a. Arson (intentionally starting a fire) Yes No b. Burglary (entry of a building or vehicle to commit a theft or other crime) Yes No c. Robbery (theft from another person using weapon or force) Yes No d. Homicide Yes No e. Theft Yes No f. Forgery Yes No g. Kidnaping Yes No h. Extortion (blackmail) Yes No i. Embezzlement (theft of money or other valuables entrusted to you) Yes No j. Rape (sexual intercourse by force) Yes No k. Any other forcible sex act (oral copulation, sodomy, etc.) Yes No l. Assaulted or hit another person Yes No m. Hit your spouse, girlfriend, boyfriend, etc. Yes No n. Witnessed or been the victim of domestic violence Yes No o. Been involved in a fight, whether you started it or not Yes No If you answered yes, check the appropriate box: 1-5 fights 6-10 fights fights More than 15 fights If yes to any of the above, please indicate the question and explain:

6 2. Have you ever been accused of stealing from an employer? Yes No Explain: 3. Have you ever illegally used or experimented with any of the following substances, drugs, or narcotics? (Used any of the following list of narcotics not prescribed by doctor by the means of injection, tasting, inhaling, smoking, snorting, or hotboxing.) DRUG *Please indicate the month and year for first and last use of the drug. AMPHETAMINES: Amp, Black Bombers, Crank, Little Bomb, Speed, Nitro Quartz, Johnny Go Fast, Uppers, Moni Bennie, Road Dope, Pink Hearts, UPS, Pep Pills Copilots, Bumble-bees, Hearts, Footballs, Wake-Ups, Truck Drivers, Eye Openers, Cross Tops, White Crosses, Crystals, Black Mollies, Peaches, Roses, Whites, Bennies, Dexies. AMYL NITRITE: Pearls, Ames, Amy, Poppers, Snappers. First used Last use Total times used BARBITURATES: Marshmellows, Reds Mickey, Ups and Downs, Downers, Barbs, Nimbies, Nemmies, Yellows, Yellow Jackets, Blues, Blue Birds, Blue Devils, Red Birds, Pinkies, Pink Ladies, Rainbows, Double Trouble, Tooles, Christmas Trees. BUTYL NITRITE: Rush, Quick Silver, Thrust, White Out, Bolt, Bullet, Locker Room, Climax, Doctor, Essence, Exotic. CHLOROHYDROCARBONS: Aerosol Sprays, Cleaning fluids, Polish Remover, Rubber Cement, Liquid Paper, Paint Thinner HASHISH: Hash. HASHISH OIL: Hash Oil. YES NO

7 FLOURINATED HYDROCARBONS: Hair Spray, Whipped Cream, Computer Cleaner. (continued...) Have you ever illegally used or experimented with any of the following substances, drugs, or narcotics? DRUG *Please indicate the month and year for first and last use of the drug. MARIJUANA: Bud, Chronic, Primo, Skunk Weed, Gungi, Cess, Cheeba, Rope, Blunt, Endo, Boom, Pot Reefer, Grass Weed, Dope, Ganja, Mary Jane, Acapulco, Gold, Columbian gold, Joint, Roach, Tai Sticks, Doobie. METHAMPHETAMINES: Crack, Crystal Meth., Speed, Glass, Peanut Butter, Natzi Vitamins, Hydro, Ice, Co-pilot, Fire, chalk and Ice. METHAQUALONE: Quaaludes, Ludes, Sopor, Black Beauties. NITROUS OXIDE: Laughing Gas, Whip-Its, Nitro, Buzz Bomb, Shoot The Breeze, Noss, N20. STEROIDS: Anadrol, A-50, Anavar, D-Ball, Winstrol, Winstrol 5, Parabolin, Premobolan, Proviron. TETRAHYDROCANNABINOL: THC COCAINE: Coke, Caine, Squirrel, Toot, Yeyo, Basuco, Bolo, Baby T, Beam Me Up Scottie, Snow, Nose Candy, Flake, Blow, Big C, Lady, White, Snowbird. CRACK COCAINE: Crack, Rock, Freebase, Boulders, Sheet Rock, Yahoo, Yeaho. DESIGNER: Synthetic Heroin, China White, New Heroin, PCPY, PCE, PCP. YES NO

8 HEROIN: Chieva, China, Chinese Red, Mexican Brown, Poppy, Speedball, Trash, Crap, Smack, Horse Mud, Brown Sugar, Junk, Black Tar, Big H, Pure Gram, Cap, Bindle, Spoon, A Fix. LYSERGIC ACID: LSD, Acid, Microdot, Paperboy, Bart Simpson, Big D, Sunshine, L, Paper Acid, Purple Haze, White Lighting, Blue Heaven, Sugar Cubes, Tabs. MESCALINE: Mesc., Blue Caps, Buttons, Chief, Moon, San Pedro, Topi, Cactus Head, Cactus Button. (continued...) Have you ever illegally used or experimented with any of the following substances, drugs, or narcotics? DRUG *Please indicate the month and year for first and last use of the drug. MORPHINE: Pectoral Syrup, Miss Emma, Blue Mister, Morf. OPIUM: Joy Plant, Red Rock, Paregoric, Dover s Powder, Parepectolin. PEYOTE: Buttons, Cactus, Bad Seed, Cacti Joint, P, Mescy Nubs, Seni Tops, Shaman. PHENCYCLIDINE: PCP, Juice, Cadillac, Jet Fuel, Super Kools, Zombie Weed, Animal Trang, Hog, Angel Dust, Love Boat, Lovely, Killer Weed, Whack, Dust, Sherms. PSILOCYBIN: Magic Mushrooms, Shrooms, Mexican Mushrooms, Pizza Toppers, Caps. GHB: Grievous Bodily Harm, G, Georgia Home Boy, Liquid Ecstasty, Liquid X, Liquid E, Gamma-Oh, Goop, EZ Lay. ROPHYNOL: Roofies, Ruffles, Rpohies, Forget Me Pill. KETAMINE: Special K, Super K, K Vitamin K, Cat Valium. YES NO

9 FENTANYL: Tango and Cash, Apache, Murder8, Poison, King Ivory, White Jackpot. DMT: Businessman s high, Businessman s LSD, Businessman s special, Businessman s trip, Businessman s high. MDMA: Ecstasy, Vitamin E, Love Drug, Lucky Charmz, Mitisubishi, Clarity, Adam, Lover s Speed, Beans, Biscuits, Candy, Jellie Beans, Party Favors, Smurfs, Rolls, X, XTC, Beavis and Butthead, Pikachu, Vitiamins. OTHERS: 4. Have you used any illegal drugs in the last year? Yes No If yes, when? Substance(s): Number of times: Last time (date): 5. Have you ever sold narcotics or drugs, including marijuana? Yes No If yes, total profit: Substance(s): Number of times: Last time (date):

10 6. Have you ever furnished, manufactured, cultivated, or possessed any drug, narcotic, or other illegal substance? Yes No Substance: Explain: 7. Have you committed any crimes not previously mentioned? Yes No If yes, please explain: 8. Have you ever been accused or been the victim of sexual harassment or discrimination in the work place? Yes No Explain:

11 I am aware that any false statement or omission on this questionnaire will cause my name to be removed from the eligibility list, or be cause for immediate dismissal if any appointment was made. Do you understand this questionnaire? Yes No Do you have any questions about this questionnaire? Yes No X Print Name Social Security No. Signature Date

12 LOS ANGELES COUNTY SHERIFF S DEPARTMENT HEIGHT-WEIGHT RELATIONSHIP: Although there are no minimum or maximum height requirements, the height-weight relationship of each applicant must either (1) fall within the ranges in the following table, or (2) if the applicant s height is not included on the table, found to be acceptable after individual evaluation. Height measurements are made without shoes. Weight measurements are made without shoes and coat. Applicants whose height. Individuals who do not meet the standard shall have their body fat measured. Female candidates whose body fat is 33% or less may qualify. Male candidates whose body fat is 22% or less may qualify. MALE HEIGHT WEIGHT HEIGHT WEIGHT 5 ft. 0 in. 110 lbs. To 143 lbs. 5 ft. 10 in. 144 lbs. To 185 lbs. 5 ft. 1 in. 112 lbs. To 146 lbs. 5 ft. 11 in. 148 lbs. To 191 lbs. 5 ft. 2 in. 115 lbs. To 149 lbs. 6 ft. 0 in. 152 lbs. To 197 lbs. 5 ft. 3 in. 118 lbs. To 152 lbs. 6 ft. 1 in. 156 lbs. To 203 lbs. 5 ft. 4 in. 121 lbs. To 155 lbs. 6 ft. 2 in. 160 lbs. To 209 lbs. 5 ft. 5 in. 124 lbs. To 158 lbs. 6 ft. 3 in. 164 lbs. To 215 lbs. 5 ft. 6 in. 128 lbs. To 163 lbs. 6 ft. 4 in. 168 lbs. To 221 lbs. 5 ft. 7 in. 132 lbs. To 168 lbs. 6 ft. 5 in. 172 lbs. To 227 lbs. 5 ft. 8 in. 136 lbs. To 173 lbs. 6 ft. 6 in. 176 lbs. To 233 lbs. 5 ft. 9 in. 140 lbs. To 179 lbs. 6 ft. 7 in. 180 lbs. To 239 lbs. FEMALE HEIGHT WEIGHT HEIGHT WEIGHT 5 ft. 0 in. 95 lbs. To 129 lbs. 5 ft. 10 in. 131 lbs. To 180 lbs. 5 ft. 1 in. 98 lbs. To 132 lbs. 5 ft. 11 in. 135 lbs. To 186 lbs. 5 ft. 2 in. 101 lbs. To 135 lbs. 6 ft. 0 in. 139 lbs. To 192 lbs. 5 ft. 3 in. 104 lbs. To 138 lbs. 6 ft. 1 in. 143 lbs. To 197 lbs. 5 ft. 4 in. 107 lbs. To 144 lbs. 6 ft. 2 in. 147 lbs. To 204 lbs. 5 ft. 5 in. 111 lbs. To 150 lbs. 6 ft. 3 in. 151 lbs. To 210 lbs. 5 ft. 6 in. 115 lbs. To 156 lbs. 6 ft. 4 in. 155 lbs. To 216 lbs. 5 ft. 7 in. 119 lbs. To 162 lbs. 6 ft. 5 in. 159 lbs. To 222 lbs. 5 ft. 8 in. 121 lbs. To 168 lbs. 6 ft. 6 in. 163 lbs. To 228 lbs. 5 ft. 9 in. 127 lbs. To 174 lbs. 6 ft. 7 in. 167 lbs. To 234 lbs. I have read the Height/Weight requirements above and understand that I will not qualify for the position, if I do not meet the standards as indicated. PRINT NAME : SIGNATURE : DATE :

16 S.T.A.R.S. Center Quad Area, South Colima Road, Whittier, CA 90604

TABLE 3 Trends in 30-Day Prevalence of Use of Various Drugs in Grades 8, 10, and 12

TABLE 3 Trends in 30-Day Prevalence of Use of Various Drugs in Grades 8, 10, and 12 TABLE 3 Any Illicit Drug a 8th Grade 5.7 6.8 8.4 10.9 12.4 14.6 12.9 12.1 12.2 11.9 11.7 10.4 9.7 8.4 8.5 8.1 7.4 7.6 8.1 9.5 8.5 7.7 8.7 8.3 8.1 6.9 7.0 7.3 +0.3 10th Grade 11.6 11.0 14.0 18.5 20.2 23.2