Employee Examination Notification Form


Under the Employee Polygraph Protection Act of 1988,
you have a number of rights in connection with the
administration of a lie-detection examination.

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY:

You may not be required to take this test as a condition of employment.

Any statement you make during the test can be used against
you in case of charges, discipline or other adverse action.

The company may disclose to government agencies any
admission of criminal activities you make during the test.

You may not be discharged, disciplined, or denied employment
or a promotion on the basis of the polygraph results alone,
without additional evidence.

You can terminate the test at any time.

You may not be asked questions designed to degrade
or needlessly intrude on your personal privacy.

You may be exempt from the test if you have a sufficient
physician's statement certifying that you have a medical
or physiological condition or you are undergoing treatment
that could cause abnormal responses during the test.

You have a right to consult with legal counsel
or an employee representative before the test.
________________________________________________________________________

(EMPLOYEE)

I have read and clearly do understand the foregoing notice
of my rights relating to the administering and use of a polygraph
('lie detector') examination by my employer, and

I HAVE DECIDED:

( ) NOT TO TAKE THE TEST.
I understand I can not be terminated or otherwise discharged
solely for refusing to take the test.But my employer may terminate
or otherwise take disciplinary action against me if my employer has
reasonable suspicion that I was involved in the incident or activity
being investigated, if I had access to the property, and all other
requirements of law have been satisfied.

( ) TO TAKE THE TEST.

NOTICE DATE:

_________________________

PRINT NAME OF EMPLOYEE

_____________________________________________

EMPLOYEE SIGNATURE

_________________________________________________

LOCATION OF TEST

_____________________

WITNESS

______________________

This examination will be given on

____________________

Time

__________ AM/PM




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