"Background Investigation Questionnaire" - New York City

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;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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The City of New York
Department of Investigation
th
80 Maiden Lane, 17
Floor
New York, NY 10038
(212) 825-5911
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 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
_________________
BIQ (June 2018)
1
The City of New York
Department of Investigation
th
80 Maiden Lane, 17
Floor
New York, NY 10038
(212) 825-5911
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 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
_________________
BIQ (June 2018)
1
DEPARTMENT OF INVESTIGATION
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 49
(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.
Other Social
If you have ever used or been issued a Social Security
Security Number
number other than the one listed in response to Question 5,
N/A
Used
provide details below.
Other Social Security Number
Dates Used (Month/Year)
Reason Used/Issued
to
Authorization to Work in the United States
7.
I am legally authorized to work in the United States.
I am not legally authorized to work in the United States.
Provide details below, including your plan to resolve the matter, and whether your agency has
been notified. Include copies of any correspondence you have sent to or received from
the United States government in your effort to resolve this matter.
Details
8.
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
Check here if additional information is provided in the addendum.
3
Social Media Accounts and Personal Websites
9.
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)
10.
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
Check here if additional information is provided in the addendum.
4
Spouse or Domestic Partner
11.
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
Former Spouse or Domestic Partner
12.
If you have been legally separated, divorced, or widowed, or have a terminated
domestic partnership, provide details below.
N/A
Include a copy of your separation agreement, divorce decree, or termination
statement with your background paperwork.
Legally Separated
Divorced
Widowed
Terminated Domestic Partnership
Spouse or Domestic Partner’s Name
Date of Action or Death
Date of Birth
(Last, First)
(Month/Day/Year)
Family Members
13.
List all of the following family members, whether living or deceased: mother and father
(including step), brothers and sisters (including half and step), children (including step), and
dependents. For each family member, check all boxes that apply. Use the addendum on page
49 to list additional family members.
If you indicate “Deceased,” do not include an address. If you indicate “Identity
Unknown,” leave the remaining details for that person blank.
Parent
Mother
Father
Stepmother
Stepfather
Deceased
Identity Unknown
Name (Last, First)
Date of Birth
Street Address
City, State, ZIP Code
Check here if additional information is provided in the addendum.
5