"Supplemental Background Investigation Questionnaire" - New York City

Supplemental Background Investigation Questionnaire is a legal document that was released by the New York City Department of Investigation - a government authority operating within New York City.

Form Details:

  • Released on June 1, 2018;
  • The latest edition currently provided by the New York City Department of Investigation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York City Department of Investigation.

ADVERTISEMENT
ADVERTISEMENT

Download "Supplemental Background Investigation Questionnaire" - New York City

829 times
Rate (4.6 / 5) 58 votes
The City of New York
Department of Investigation
th
80 Maiden Lane, 17
Floor
New York, NY 10038
(212) 825-5911
Supplemental Background Investigation Questionnaire
Your Terms and Conditions of Appointment will not be approved unless you provide all information
requested and cooperate fully with this background investigation. If you fail to do so, you may incur
disciplinary action, including the termination of your employment or removal from your appointment.
Department of Investigation (DOI) background investigations are detailed and thorough; information
you provide will be verified during the investigation.
A false statement or intentional omission made in this questionnaire, or in connection with this
background investigation, may result in the imposition of disciplinary penalties, including but not
limited to termination of employment or removal from appointment, disqualification from future
employment or appointment, and criminal prosecution.
This Supplemental Background Investigation Questionnaire is not a public document and cannot be
obtained through a Freedom of Information Act request. However, this questionnaire may be provided,
upon request, for use in another government agency’s background investigation, or for the purposes
of administrative action (e.g., disciplinary proceedings) by your agency, the City’s Office of
Administrative Trials and Hearings, the Conflicts of Interest Board, or others.
DOI recommends that you keep a copy of this completed questionnaire for your personal
records, and for reference in completing any future DOI Background Investigation
Questionnaires.
I have read and I understand this information.
Initial and date: ___________
For DOI Use Only:
Candidate’s Name
____________________________
Phone Number
_________________
Investigator
____________________________
Interview Date
_________________
Supervisor
____________________________
Review Date
_________________
SBIQ (June 2018)
1
The City of New York
Department of Investigation
th
80 Maiden Lane, 17
Floor
New York, NY 10038
(212) 825-5911
Supplemental Background Investigation Questionnaire
Your Terms and Conditions of Appointment will not be approved unless you provide all information
requested and cooperate fully with this background investigation. If you fail to do so, you may incur
disciplinary action, including the termination of your employment or removal from your appointment.
Department of Investigation (DOI) background investigations are detailed and thorough; information
you provide will be verified during the investigation.
A false statement or intentional omission made in this questionnaire, or in connection with this
background investigation, may result in the imposition of disciplinary penalties, including but not
limited to termination of employment or removal from appointment, disqualification from future
employment or appointment, and criminal prosecution.
This Supplemental Background Investigation Questionnaire is not a public document and cannot be
obtained through a Freedom of Information Act request. However, this questionnaire may be provided,
upon request, for use in another government agency’s background investigation, or for the purposes
of administrative action (e.g., disciplinary proceedings) by your agency, the City’s Office of
Administrative Trials and Hearings, the Conflicts of Interest Board, or others.
DOI recommends that you keep a copy of this completed questionnaire for your personal
records, and for reference in completing any future DOI Background Investigation
Questionnaires.
I have read and I understand this information.
Initial and date: ___________
For DOI Use Only:
Candidate’s Name
____________________________
Phone Number
_________________
Investigator
____________________________
Interview Date
_________________
Supervisor
____________________________
Review Date
_________________
SBIQ (June 2018)
1
DEPARTMENT OF INVESTIGATION
SUPPLEMENTAL BACKGROUND INVESTIGATION QUESTIONNAIRE
INSTRUCTIONS
This questionnaire must be typed, or completed in blue or black ink.
Every question must be answered completely and accurately.
Do not leave any question blank. If a question does not apply to you, indicate “N/A”
(not applicable).
If you need more space to answer a question, use the addendum provided on page 40
(make copies if needed). Check the box at the bottom of the page on which the
question appears, and note in the addendum the question and page number.
This questionnaire is an affidavit. Upon completion, it must be signed and sworn to
before a Notary Public or Commissioner of Deeds.
I have read and I understand these instructions.
Initial and date: ___________
PERSONAL INFORMATION
1.
Full Name
Last Name
First Name
Middle Name
Jr., II, etc.
N/A
N/A
2.
Other Names
If you have ever used or been known by another name, including a
N/A
Used
maiden name or alias, provide details below.
Dates Used
Full Name
Reason Used
(Month/Year)
to
to
3.
Date of Birth
4.
Place of Birth
Month
Day
Year
City
State
Country
5.
Social Security Number
Check here if additional information is provided in the addendum.
2
6.
Contact Information
Enter your e-mail address(es) and phone number(s).
N/A
Work E-mail Address
N/A
Personal E-mail Address
Desk
Cell
Primary Work Phone Number
Desk
Cell
N/A
Secondary Work Phone Number
Home
Cell
Primary Personal Phone Number
Home
Cell
N/A
Secondary Personal Phone Number
Social Media Accounts and Personal Websites
7.
Provide the information below for all social media accounts, personal websites, and blogs used
or maintained by you or your spouse or domestic partner.
Spouse or Domestic Partner’s
Your Screen Name (e.g., username,
Type of Site
Screen Name (e.g., username,
profile name, handle)
profile name, handle)
N/A
N/A
Blog
URL:
URL:
N/A
N/A
Facebook
N/A
N/A
Instagram
N/A
N/A
LinkedIn
N/A
N/A
Personal Website
URL:
URL:
N/A
N/A
Reddit
N/A
N/A
Snapchat
N/A
N/A
Tumblr
N/A
N/A
Twitter
N/A
N/A
YouTube
N/A
N/A
Other (specify)
Check here if additional information is provided in the addendum.
3
8.
Current Marital Status (Select One)
Single (Never Married)
Married
Domestic Partner
Domestic Partner applies to persons who have a
registered domestic partnership pursuant to New
York City Administrative Code Section 3-241, or a
Legally Separated
domestic partnership registered in accordance with
New York City Mayoral Executive Order No. 123,
Divorced
dated August 7, 1989, or New York City Mayoral
Executive Order No. 48, dated January 7, 1993.
Widowed
Spouse or Domestic Partner
9.
If you have a spouse or domestic partner, provide their information below.
N/A
Spouse
Domestic Partner
Date of Marriage
Name
Social Security
Date of Birth
or Registration
(Last, First, and Maiden)
Number
(Month/Day/Year)
(Month/Day/Year)
Name and Address of Business or Employer
Spouse or Domestic Partner’s Job Title
of Spouse or Domestic Partner
Full-time
Part-time
Retired
N/A
Check here if additional information is provided in the addendum.
4
Family Members Employed by the City of New York
10.
Provide details below if any family member is employed by the City of New York
(or any of its agencies), or is employed as a director, officer, principal, or partner
of any organization (non-City entity) that does business with the City of New
York (or any of its agencies).
Family members include parents (including step), siblings (including half and
N/A
step), children (including step), and dependents.
Doing business with the City includes receiving funds from the City, having
contracts with the City, providing materials or services to the City, having matters
pending before the City, or holding any franchise, license, permit, or other privilege
from the City.
Full Name (Last, First)
City Agency
Title/Position
and Relationship to You
or Non-City Entity
RESIDENCE INFORMATION
11.
Current Primary Residence
Select One:
Own
Rent
Other
If you selected “Other,” provide the details of your living arrangement and your relationship to the
property owner:
Month/Year
Street
City, State, ZIP Code
to Present
I understand that if the position for which I am being investigated requires
Initial and date:
New York City residency, I must comply with such requirement within the
time period established for my agency.
___________
Check here if additional information is provided in the addendum.
5