BC Public Service Security Screening Questionnaire · BC Public Service Security Screening Questionnaire Oct, 2018 Page 6 of 16 7. Within the last 15 years has regular or excessive

BC Public Service Security Screening Questionnaire Oct, 2018 Page 1 of 16

BC Public Service

Security Screening Questionnaire


Table of Contents

Section 1 – Applicant Information and Instructions ..................................... 3

Section 2 – Alcohol/Drugs ............................................................................ 4

Section 3 – Driving ....................................................................................... 7

Section 4 – Finances ...................................................................................... 8

Section 5 – Work and School ........................................................................ 9

Section 6 – Associations and Relationships................................................ 11

Section 7 – Unlawful Conduct .................................................................... 11

Section 8 – Other ......................................................................................... 15

Section 9 – Applicant Declaration and Consent ......................................... 16


Section 1 – Applicant Information and Instructions

Applicant Information (to be completed by applicant)

Surname Given Names

Home Tel. No.(inc area code) Cell Tel. No. (inc area code) Work Tel. No. (inc area code)

E-mail: Birthdate (YYYY-MM-DD)

Current Address (Apt. or Street No. | Street Name | City | Province | Postal Code | Country):

Completion Instructions

This questionnaire pertains to your honesty, integrity, and lifestyle. It is expected that you answer all questions accurately, completely and honestly. Should you be considered for continuation in the process, your answers may be verified by a variety of means including: a security interview; computer voice stress analysis, polygraph and a background character check.

Applicants should note the following when completing the questionnaire:

Your decision to complete this questionnaire is voluntary. You may withdraw from the process at any time orrefuse to provide answers to any or all of the questions in the questionnaire. However, an incompletequestionnaire will result in your disqualification from further consideration.

Deceit, dishonesty or non-disclosure may lead to your disqualification from this and future competitions.

Information provided in this questionnaire regarding serious, recent or ongoing unlawful activity may beinvestigated further and/or disclosed to the appropriate law enforcement agency as required by law.

You are not required to reveal any information related to a conviction for which a pardon has been received ora conviction under the Young Offenders Act or Youth Criminal Justice Act (Canada) that is outside therequired disclosure time-frame.

You can complete this document electronically. Please ensure that your answer is solely contained in the boxresponse; if wording is hidden from view, it cannot be reviewed. If you need more space to answer a question,attach additional pages as needed – clearly mark the question number(s) and include your name and the dateat the top of each page.

Handwritten submissions must be legible and in ink to be accepted. After completing the questionnaire, sign and date the Declaration and Consent section on the last page.

This information is collected by the British Columbia Public Service under s.26(c) of FOIPPA. Any questionsabout the collection and use of this information can be directed to the BC Public Service Agency, HR Servicesat: [email protected].

Submission Instructions

The completed form must be returned to the “BCSS Office of Professional Standards” by emailing it to Inspector Koreen Carl at “[email protected]”.

mailto:[email protected]


Section 2 – Alcohol/Drugs

1. Within the last 15 years have you used, or experimented with illegal drugs? No Yes If

yes, complete the table below.

Drug Date of Last Use Frequency of Use Average Amount Used

Marijuana (pre-Oct 17/2018)

Hash/Hash Oil

Cocaine

Crack

Heroin

Mushrooms

Acid/LSD

Methamphetamine

Ecstasy

Steroids

Inhalants (e.g. glue, gasoline)

Mescaline (e.g. Peyote)

Crystal Meth

Other (specify)

2. Within the last 15 years have you misused any prescription or non-prescription drugs? No

Yes If yes, complete the table below.

Drug Date of Last Use Frequency of Use Average Amount Used

Methadone

Percocet

Percoden/Percodan

Valium

Prozac

Xanax

Ritalin

Oxcycodone (e.g. OxyContin)

Codeine

Dilaudid

Morphine

Other (specify)


3. Within the last 15 years have you purchased, sold, or given anyone illegal drugs including

steroids? No Yes If yes, provide complete details.

4. Within the last 15 years have you grown, manufactured, imported or transported illegal drugsor contravened laws regarding the growing, preparing, using, or distributing cannabis or cannabisproducts? No Yes If yes, explain.

5. Within the last 15 years have you given or sold prescription drugs to anyone (adults or minors)?

No Yes

If yes, explain.

6. Within the last 15 years have you had contact with the police as a result of being under the

influence of alcohol, cannabis and/or illegal drugs? No Yes If yes, provide complete details.


7. Within the last 15 years has regular or excessive alcohol and/or drug use resulted in a negative

incident in any aspect of your life – at home, work or school? No Yes If yes, explain.

8. Within the last 15 years have you consumed alcohol or cannabis or used illegal or prescription drugs during working or on-call hours where your ability to do your job may have been affected?No Yes If yes, explain.

9. Within the last 15 years have you driven while under the influence of alcohol and/or drugs?

No Yes If yes, provide complete details of the circumstances.

10. Within the last 15 years are you now or have you been addicted to alcohol and/or drugs? No

Yes If yes, explain.


Section 3 – Driving

11. Within the last 5 years have you applied for a drivers licence and been denied? No Yes

If yes, explain.

12. Within the last 5 years has your driver’s licence been revoked, suspended, or placed on

probationary status? No Yes If yes, provide complete details including whether you

drove during this period.

13. Within the last 5 years, to the best of your recollection, list all of the traffic offences you havebeen charged with in BC and elsewhere? Provide complete details for each offence.

14. Within the last 5 years, to the best of your recollection, list all of the motor vehicle collisions thatyou were involved with and deemed completely or partially at fault in BC and elsewhere.Provide complete details for each collision.


Section 4 – Finances (complete this section only if you are applying for a Sheriff or BCCorrections position)

15. Within the last 7 years has a collection agency been assigned to your outstanding debts?

No Yes If yes, explain.

16. Within the last 7 years have you had your wages garnisheed? No Yes If yes, explain.

17. Within the last 7 years have you declared bankruptcy? No Yes If yes, explain.

18. Do you have any debts you will not be able to pay back? No Yes If yes, explain.


Section 5 – Work and School

19. Within the last 10 years have you been fired or asked to resign from a job? No Yes

If yes, explain.

20. Within the last 10 years have you been formally disciplined or documented for inappropriate or

unauthorized conduct at work? No Yes If yes, explain.

21. Within the last 10 years have you been denied a job with the military, the police, an intelligence

service or any other law enforcement agency? No Yes If yes, list the job applied for

and explain the circumstances.

22. Within the last 10 years have you been suspended, expelled, or formally reprimanded by a

secondary or post-secondary institution? No Yes If yes, list the institution and explain

the circumstances and the outcome.


23. Within the last 10 years have you cheated on any form of examination or put forward someone

else’s work without their permission for your personal benefit? No Yes If yes, explain.

24. Have you ever knowingly misused or wrongfully disclosed private or confidential information?


25. Have you ever covered up for a colleague’s misconduct at work? No Yes If yes,

explain.

26. Have you ever discriminated against someone at work because of their race, colour of skin,

sexual orientation, or religion? No Yes If yes, explain.


27. Have you ever used a computer or other electronic device at work in a way that was not

sanctioned by your employer? No Yes If yes, explain.

Section 6 – Associations and Relationships

28. Are you or have you ever been associated with any gang, criminal group, terrorist group,militant group, or other extremist organization that engages in unlawful activities?


29. Are you aware that any of your family members or friends are involved in any criminal activity,drug use or associated with any gang, criminal group, terrorist group, militant group, or otherextremist organization that engages in unlawful activities?


Section 7 – Unlawful Conduct 30. Within the last 10 years have you been investigated, detained, or arrested, or charged by the

police or any law enforcement agency or had your information recorded by the police in relation

to an investigation? No Yes If yes, provide complete details for each instance.


31. Have you ever been involved in any dishonest or criminal behaviour in your past or currentemployment (e.g. theft, fraud, filing false or misleading expense claims, etc)?


32. Have you ever had sexual involvement with any person without their consent (e.g. persons who

could not give their consent due to alcohol or drugs)? No Yes If yes, provide details.

33. While an adult (over age 17), have you engaged in, or tried to engage in, a sexual act thatinvolved a child or under age person (whether in person or via the phone/internet)?

No Yes If yes, provide details.

34. While an adult (over age 17), have you viewed, downloaded, printed, shared, or produced anysexually explicit material involving an underage person?

No Yes If yes, provide details.


35. Have you ever engaged in any illegal activity using an electronic device and/or the internet (e.g.

hacking, harassment, theft of copyrighted material)? No Yes If yes, explain.

36. As an adult (over age 17) within the last 10 years, have you threatened physical violence

towards another person or threatened to damage their property? No Yes If yes,

explain.

37. While an adult (over age 17), have you been physically violent towards another person, child or

adult? No Yes If yes, explain and indicate if the violence involved physical contact or

use of a weapon.


38. Have you ever made or caused to be made a false or misleading insurance claim with theInsurance Corporation of B,C. (I.C.B.C.), the Workers Compensation Board (W.C.B.) or any

other insurance company? No Yes If yes, explain.

39. Have you ever filed a false tax return or customs declaration? No Yes If yes, explain.

40. Have you ever had a search warrant, peace bond, restraining order, or protection order served

on you? No Yes If yes, explain.

41. (Complete this question only if you are applying for a Conservation Officer position) Have youever committed a violation of environmental legislation, including hunting or fishing related

offences? No Yes If yes, explain and be sure to list all offences whether charged or

not.


42. Have you ever been involved in any criminal behaviour or other unlawful activity not covered by this questionnaire No Yes If yes, provide complete details for each instance.

Section 8 – Other

43. Have you ever borrowed over $200 in order to gamble or to cover a gambling loss?


44. (Complete this question only if you are applying for a Conservation Officer or Sheriff position)

Have you ever been refused a gun permit or license or had a permit or license revoked? No

Yes If yes, explain.

45. Are there now or have there ever been any civil judgements outstanding or pending against

you for injuries, damages, or non-payment of debts? No Yes If yes, explain.


Section 9 – Applicant Declaration and Consent

I, the undersigned, do hereby consent to the disclosure of the personal information collected in the Pre- Employment Security Screening Questionnaire to the Personnel Security Screening Office (hereinafter the PSSO) for the purpose of assessing my suitability, reliability and security as it relates to employment with

the BC Public Service.

I recognize that the PSSO is collecting my personal information solely for the purpose noted above and in accordance with the provisions of Section 8(1) of the Privacy Act of Canada, and Section 26(c) of the British Columbia Freedom of Information and Protection of Privacy Act (FOIPPA). Any questions about the collection and use of this information can be directed to the Personnel Security Screening Office using the contact information noted in Section 1 (Submission Instructions).

I certify, to the best of my knowledge, that the information I have provided in the Pre-Employment Security Screening Questionnaire is complete, honest and accurate. I understand that a false statement or omission of facts herein may disqualify me from consideration or result in my subsequent termination for cause if I am employed.

Applicant Name (please print) Applicant’s Signature Date Signed

(Please print the completed questionnaire and then sign and date by hand)

Surname: Given Names: Home Tel Noinc area code: Cell Tel No inc area code: Work Tel No inc area code: Email: Birthdate YYYYMMDD: Current Address Apt or Street No Street Name City Province Postal Code Country: Within the last 15 years have you used or experimented with illegal drugs: OffMarijuana preOct 172018: OffDate of Last UseMarijuana preOct 172018: Frequency of UseMarijuana preOct 172018: Average Amount UsedMarijuana preOct 172018: HashHash Oil: OffDate of Last UseHashHash Oil: Frequency of UseHashHash Oil: Average Amount UsedHashHash Oil: Cocaine: OffDate of Last UseCocaine: Frequency of UseCocaine: Average Amount UsedCocaine: Crack: OffDate of Last UseCrack: Frequency of UseCrack: Average Amount UsedCrack: Heroin: OffDate of Last UseHeroin: Frequency of UseHeroin: Average Amount UsedHeroin: Mushrooms: OffDate of Last UseMushrooms: Frequency of UseMushrooms: Average Amount UsedMushrooms: AcidLSD: OffDate of Last UseAcidLSD: Frequency of UseAcidLSD: Average Amount UsedAcidLSD: Methamphetamine: OffDate of Last UseMethamphetamine: Frequency of UseMethamphetamine: Average Amount UsedMethamphetamine: Ecstasy: OffDate of Last UseEcstasy: Frequency of UseEcstasy: Average Amount UsedEcstasy: Steroids: OffDate of Last UseSteroids: Frequency of UseSteroids: Average Amount UsedSteroids: Inhalants eg glue gasoline: OffDate of Last UseInhalants eg glue gasoline: Frequency of UseInhalants eg glue gasoline: Average Amount UsedInhalants eg glue gasoline: Mescaline eg Peyote: OffDate of Last UseMescaline eg Peyote: Frequency of UseMescaline eg Peyote: Average Amount UsedMescaline eg Peyote: Crystal Meth: OffDate of Last UseCrystal Meth: Frequency of UseCrystal Meth: Average Amount UsedCrystal Meth: Other specify: OffDate of Last UseOther specify: Frequency of UseOther specify: Average Amount UsedOther specify: No_2: OffYes_2: OffMethadone: OffDate of Last UseMethadone: Frequency of UseMethadone: Average Amount UsedMethadone: Percocet: OffDate of Last UsePercocet: Frequency of UsePercocet: Average Amount UsedPercocet: PercodenPercodan: OffDate of Last UsePercodenPercodan: Frequency of UsePercodenPercodan: Average Amount UsedPercodenPercodan: Valium: OffDate of Last UseValium: Frequency of UseValium: Average Amount UsedValium: Prozac: OffDate of Last UseProzac: Frequency of UseProzac: Average Amount UsedProzac: Xanax: OffDate of Last UseXanax: Frequency of UseXanax: Average Amount UsedXanax: Ritalin: OffDate of Last UseRitalin: Frequency of UseRitalin: Average Amount UsedRitalin: Oxcycodone eg OxyContin: OffDate of Last UseOxcycodone eg OxyContin: Frequency of UseOxcycodone eg OxyContin: Average Amount UsedOxcycodone eg OxyContin: Codeine: OffDate of Last UseCodeine: Frequency of UseCodeine: Average Amount UsedCodeine: Dilaudid: OffDate of Last UseDilaudid: Frequency of UseDilaudid: Average Amount UsedDilaudid: Morphine: OffDate of Last UseMorphine: Frequency of UseMorphine: Average Amount UsedMorphine: Other specify_2: OffDate of Last UseOther specify_2: Frequency of UseOther specify_2: Average Amount UsedOther specify_2: Within the last 15 years have you purchased sold or given anyone illegal drugs including: OffWithin the last 15 years have you grown manufactured imported or transported illegal drugs: OffWithin the last 15 years have you given or sold prescription drugs to anyone adults or minors: OffWithin the last 15 years has regular or excessive alcohol andor drug use resulted in a negative: OffWithin the last 15 years have you driven while under the influence of alcohol andor drugs: OffNo_10: OffYes_10: Off11 Within the last 5 years have you applied for a drivers licence and been denied: Offprobationary status: Off15 Within the last 7 years has a collection agency been assigned to your outstanding debts: OffIf yes explain: Offundefined_3: OffIf yes explain_3: Off19 Within the last 10 years have you been fired or asked to resign from a job: Off20 Within the last 10 years have you been formally disciplined or documented for inappropriate or: Offservice or any other law enforcement agency: Offsecondary or postsecondary institution: Off23 Within the last 10 years have you cheated on any form of examination or put forward someone: Off24 Have you ever knowingly misused or wrongfully disclosed private or confidential information: Off25 Have you ever covered up for a colleagues misconduct at work: Off26 Have you ever discriminated against someone at work because of their race colour of skin: Off27 Have you ever used a computer or other electronic device at work in a way that was not: Offmilitant group or other extremist organization that engages in unlawful activities: Offextremist organization that engages in unlawful activities: Offpolice or any law enforcement agency or had your information recorded by the police in relation: Offemployment eg theft fraud filing false or misleading expense claims etc: Off32 Have you ever had sexual involvement with any person without their consent eg persons who: Offinvolved a child or under age person whether in person or via the phoneinternet: Offsexually explicit material involving an underage person: Off35 Have you ever engaged in any illegal activity using an electronic device andor the internet eg: OffNo_34: OffYes If yes: Off37 While an adult over age 17 have you been physically violent towards another person child or: OffIf yes explain_4: OffIf yes explain_5: OffIf yes explain_6: OffIf yes explain and be sure to list all offences whether charged or: Off42 Have you ever been involved in any criminal behaviour not covered by the other questions in: Off43 Have you ever borrowed over 200 in order to gamble or to cover a gambling loss: OffNo_42: OffYes_41: Off45 Are there now or have there ever been any civil judgements outstanding or pending against: OffApplicant Name please print: Within the last 15 years have you had contact with the police as a result of being under the: Offduring working or oncall hours where your ability to do your job may have been affected: OffText1: Text2: Text3: Text4: Text5: Text7: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text6: Text18: Text19: Text20: Text21: Text22: Text23: Text24: Text25: Text26: Text27: Text28: Text29: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45:

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BC Public Service Security Screening Questionnaire · BC Public Service Security Screening Questionnaire Oct, 2018 Page 6 of 16 7. Within the last 15 years has regular or excessive