*CLAYTON POLYGRAPH SERVICES IS NOT RESPONSIBLE FOR DETERMINING WHICH EMPLOYEE MUST BE TESTED OR WHICH EMPLOYEE QUALIFIES UNDER E.P.P.A. GUIDELINES*

PLEASE HAVE THIS FORM COMPETED PRIOR TO ANY EXAMINATION OF EMPLOYEES

(Company Name)

EMPLOYEE POLYGRAPH EXAMINATION REQUEST 

Dear ______________________________, In accordance with the Rules and Regulations of the Polygraph Protection Act of 1988, I am requesting that you submit to a polygraph/lie detector examination. Reason For Examination An internal investigation is in progress regarding economic loss or injury suffered by your employer. The incident under investigation is as follows: _______________________________________________________________________________________________________________________________________________. In addition to mere access, your employer has a reasonable suspicion that you were involved in the incident or activity under investigation for the following reasons: _______________________________________________________________________________________________________________________________________________. You access to the property in question was ______________________________________________________________________. Your Examination Schedule Your polygraph examination has been scheduled on ___________at________. At the following location:______________________________________________________. NATURE OF THE EXAMINATION A polygraph instrument is a device which records continuosly, visually, permanently, and simultaneously changes in your cardiovascular, respiratory, and electrodermal patterns. These recordings are obtained by attaching sensors to the body at the torso, arm, and fingers. The polygraph is used for the purpose of rendering a diagnostic opinion regarding the honesty or dishonesty of an individual. The test questions are designed by the examiner during the pre-test interview and are reviewed with you prior to the testing phase. The polygraph recordings (charts) are later analyzed and an opinion is rendered based solely on these charts. DISCLOSURE OF INFORMATION The polygraph examiner may disclose information acquired from your polygraph test only to you, your employer or any court, governmental agency, arbitrator, or mediator, in accordance with due process of law, pursuant to an order from a court of competent jurisdiction. Your employer may disclose information from the test to a governmental agency, but only if the disclosed information is an admission of criminal conduct. EXAMINATION RESULTS The examiner will trasmit the test results to your employer following the examination. Prior to any adverse employment action by your employer, you must be provided with a written copy of any opinion or conclusion rendered as a result ot the test, and with a copy of the questions asked during the test along with the corresponding charted responses. Also, your employer must further interview you on the basis of the results of the test. The results of this polygraph examination may not srve as the basis for an adverse employment action withour additional supporting evidence for the purposes of an adverse employment action. MONITORING OF THE EXAMINATION Your polygraph examination may be observed or recorded. You must be advised if this is to take place. 

YOUR LEGAL RIGHTS Your have the right to obtain and consult with legal counsel or an employee representative before the examination. You cannot be required to submit to this examination. Should you refuse to take the examination, such refusal may not serve as the basis for an adverse employment action withour additonal supporting evidence. Prior to the exam, you will be provideed with a written list of intended test questions for your review and approval. Tha examiner may not ask you any question during the test that was not presented to you in writing for review before the test. You are permitted to terminate the test at any time. The examiner may not ask you questions concerning religious beliefs or affiliations, political beliefs or affiliations, beliefs or opinions regarding racial matters, anymatter relating tosexual behavior, and beliefs, affiliations, opinions or lawful activities regarding unions or labor organizations. You may not submit to the polygraph examination if there is sufficient written evidence by a physician that your are suffering from a medical or psychological condition or undergoing treatment that might cause abnormal responses during the actual testing phase. PENALTIES Any employer who violates any provision of the Employee Polygraph Protection Act of 1988 may be assessed a civil penalty of not more than $10,000 by the Secretary of Labor. Any employer who violates this Act shall also be civilly liable to the employee affected by such violation. Such employer shall be liable for such legal or equitable relief as may be appropriate, including, wages and benefits and resonable costs, including attorney’s fees. Such an action may be maintained against the employer in any Ferder or State court of competent jurisdiction. No such action may be commenced more tan 3 years after the date of the alleged violation. INSTRUCTIONS Please return one copy of this letter prior to the exam date signed by you wher indicated acknowledging that you have read this document and understand your rights under the Act. If you are under 18 years of age, we must first obtain the consent of your parent or guardian. Your employer must maintain a copy of this document for at least 3 years.

Sincerely, __________________________________ Authorized Company Representative __________________________________ Title __________________________________ Date I,_______________________________________, have read the foregoing document regarding the provisions of the Employee Polygraph Protection Act of 1988. I hereby agree to submit to such a polygraph examination at the date, time and place requested, and further acknowledge and agree to all the above-listed terms, conditions, limitations, and requirements. 

___________________________________________ 

Signature of person to be examined