Public Servant Questionnaire

This questionnaire must be filled-out by any public servant before he can ask the citizen any question. Federal law, including the Privacy Act, 5 U.S.C. 552a, 88 Stat. 1896, et seq., 1974, authorizes this.

  1. Public servant's full legal name:
  2. Public servant's residence address:
  3. Name of agency:
  4. Full legal name of supervisor and office address:
  5. Will you as a public servant uphold the constitution of the United States?
     Yes  No
  6. Did public servant provide proof of identity?
     Yes  No
  7. ID number: __________________
    Badge Number: ________________
    Bonding agency and number: _______________
  8. Will you as a public servant furnish a copy of the law or regulation that authorizes the action being taken or information requested in this case?
     Yes  No
  9. Will you as a public servant provide in writing, that portion of the law authorizing the questions asked?
     Yes  No
  10. Are answers voluntary or mandatory?
     Voluntary  Mandatory
  11. Are the questions being asked based upon a specific law or regulation, or are they a discovery process?
     Law/Regulation  Discovery Process
  12. If based on a specific law or regulation, please state:___________________________________________

  13. _________________________________________________________________________________
  14. What other uses may be made of this information?
  15. What other agencies may have access to this information?
  16. What will be the effect upon me if I should not choose to answer any or all of these questions?
  17. Name of person in government requesting this information:
  18. Is this investigation general or special?
     General  Special

Note: by ‘general,’ it means any kind of blanket investigations in which a number of persons are involved because of geography, type of business income, etc. By ‘special,’ it means any investigation of an individual nature in which others are not involved.

  1. Have you consulted, questioned, interviewed, or received information from any third party relating to this matter?
     Yes  No
    If yes, give identity of all such third parties: (Use back of sheet if more area is needed.)
    1. ___________________________________________________________________
    2. ___________________________________________________________________
    3. ____________________________________________________________________
    4. ____________________________________________________________________
  2. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information, which you seek?
     Yes  No
  3. Is there a file of records, information, or correspondence relating to me being maintained by this agency?
     Yes  No
  4. Is this agency using any information on me, which was supplied by another agency or government source?
     Yes  No
  5. Will the public servant guarantee that no department [other than the one by which he is employed] will use the information in these files?
     Yes  No

I hereby sign and affirm under the penalty of perjury that the answers are true and correct in every particular.

Signature of Public Servant

Notice : If any person or agency receives any request for information relating to me, you must advise me in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided by this act or other law(s).