Attachment 5 - PPB Background Check Forms.pdf

REQUESTOR: SEND THIS COMPLETED FORM, APPLICANT QUESTIONS, AND THE WITNESSED INFORMED CONSENT TO

EMAIL ppbbackgroundrequest@portlandoregon.gov OR INTEROFFICE 119/1542

REQUESTOR INFORMATION

DATE OF REQUEST REQUEST TYPE Contractor Volunteer City Employee

REQUESTOR NAME & DIVISION OR BUREAU

PHONE EMAIL

APPLICANT WILL BE ALLOWED TO (check all that apply)

Have unescorted access into police facilities Work/volunteer in or on police facilities

Be issued a security disc Operate a computer and view police information

Be given an office door key Be able to manipulate/change computer data

View and/or access CJIS and RMS data

LOCATION AND DESCRIPTION OF WORK TO BE PERFORMED

APPLICANT INFORMATION

APPLICANT NAME (Last, First, Middle)

Applicant aliases including maiden name(s)

Date of Birth Sex Place of Birth

Driver’s License Number

Street Address

Race Citizenship

Driver’s License State

City State Zip

Phone Email

List all states in which you have resided since age 16

Date and location of last police contact

PERSONNEL DIVISION USE ONLY

ID TYPE Non-Sworn Building Pass Volunteer Contractor List

Approved by/Assigned by Date assigned

Investigation assigned to BACKGROUND LEVEL 1 2 3

Applicant Questions

NAME (Last, First, Full Middle) _______________________________________________________________________________________________

DATE OF BIRTH _________________________ SSN _________________________

Have you ever used a Social Security Number other than the one listed above? Yes No

If so, why? ______________________________________________________________________________________________________________

Have you ever threatened to harm a co-worker or supervisor at work? Yes No If so, why? ______________________________________________________________________________________________________________

Have you ever taken money or goods from an employer without permission? Yes No When? What? ___________________________________________________________________________________________________________

Have you ever used illegal drugs (including youthful experimentation)? Yes No

Type of Drug How Many Times? Last Usage (Month/Year) Comments Cocaine or Crack Ecstasy Hallucinogens PCP / Angel Dust Heroin Other Opiates Methamphetamine Other Amphetamines Inhalants ( “Huffing” ) Other Illegal Drugs

Have you applied for a criminal justice position or access to any law enforcement facility in the past ten years? Yes No

When? Which agency? ____________________________________________________________________________________________________

Was a background investigation started? Yes No

Outcome? _______________________________________________________________________________________________________________

Have you ever been arrested? Yes No

How many times? When? Where? ___________________________________________________________________________________________

Why? Disposition? ________________________________________________________________________________________________________

Have you ever been questioned as a suspect in any crime? Yes No

Where? What crime? ______________________________________________________________________________________________________

Signature___________________________________________________________ Date_______________________

Updated 102120

NON-SWORN

Informed Consent/Release and Hold Harmless Waiver

Ensuring Confidentiality of Background Investigation Information

I recognize that the Portland Police Bureau has an obligation to ensure public safety and protect police property, equipment and records. As an applicant to the Portland Police Bureau (whether I am a contractor doing business with the Police Bureau, or as a prospective employee), I acknowledge that I must prove my suitability to access police facilities on a regular basis.

I understand that I am authorizing an investigation into aspects of my personal life to determine my fitness to access police facilities. This investigation may include contacting persons and/or organizations that have information relating to my suitability. I also understand that those persons and/or organizations may feel inhibited, intimidated or otherwise reticent about furnishing legitimate information concerning my fitness unless the confidentiality of their information can be guaranteed on a permanent basis.

I further recognize that although some of the information contained in this report is a matter of public record, or would otherwise be accessible to me, this information will be interwoven with other confidential information to which I would otherwise not be privy.

Therefore, I exonerate, release and discharge the City of Portland, the Police Bureau, its officers, agents or assigns, now and in the future, from any claim or damages, whether in law or in equity, on behalf of myself, my heirs, agents, or assigns, for their refusal to make available any and all information contained in this investigation, including but not limited to the identity of any person or organization who may have supplied information in the course of this investigation, as well as the substance of any such information supplied, even where such information has been the basis for my disqualification from further consideration.

I hereby knowingly, voluntarily, and specifically, waive any rights I may have to examine, review, or to otherwise discover the contents of this investigation and all documents related thereto, whether by request, civil service appeal, grievance, or by legal process.

I hereby declare under penalty of perjury that the foregoing statement is true to the best of my knowledge and belief.

DATE: _______________________

Signature of Applicant Printed Name of Applicant

Signature of Witness Printed Name of Witness

CITY OF PORTLAND, OREGON

Bureau of Police Charlie Hales, Mayor

Lawrence P. O’Dea III, Chief of Police 1111 S.W. 2nd Avenue Portland, OR 97204 Phone: 503-823-0000

Integrity Compassion Accountability Respect Excellence Service

Informed Consent/Release and Hold Harmless Waiver Ensuring Confidentiality of Background Investigation Information

I recognize that the Portland Police Bureau has an obligation to ensure public safety and protect police property, equipment and records. As an applicant to the Portland Police Bureau (whether I am a contractor doing business with the Police Bureau, or as a prospective employee), I acknowledge that I must prove my suitability to access police facilities on a regular basis.

I understand that I am authorizing an investigation into aspects of my personal life to determine my fitness to access police facilities. This investigation may include contacting persons and/or organizations that have information relating to my suitability. I also understand that those persons and/or organizations may feel inhibited, intimidated or otherwise reticent about furnishing legitimate information concerning my fitness unless the confidentiality of their information can be guaranteed on a permanent basis.

I further recognize that although some of the information contained in this report is a matter of public record, or would otherwise be accessible to me, this information will be interwoven with other confidential information to which I would otherwise not be privy.

Therefore, I exonerate, release and discharge the City of Portland, the Police Bureau, its officers, agents or assigns, now and in the future, from any claim or damages, whether in law or in equity, on behalf of myself, my heirs, agents, or assigns, for their refusal to make available any and all information contained in this investigation, including but not limited to the identity of any person or organization who may have supplied information in the course of this investigation, as well as the substance of any such information supplied, even where such information has been the basis for my disqualification from further consideration.

I hereby knowingly, voluntarily, and specifically, waive any rights I may have to examine, review, or to otherwise discover the contents of this investigation and all documents related thereto, whether by request, civil service appeal, grievance, or by legal process.

Signature of Applicant Printed name of applicant

I attest the applicant subscribed the above before me on this day of , 20 in the City of

Portland, County of Multnomah, State of Oregon.

Notary Public for the State of Oregon

EXHIBIT C