Obtained from:
http://campus.umr.edu/police/cvsa/compar6.htm COMPUTER VOICE STRESS ANALYZER
CVSA Comparison Study
ATTACHMENT A
POLYGRAPH TREATMENT QUESTIONNAIRE
Name: ___________________________________________________ Date:____________
Your last examination was on_____________________ . Since then have you: (circle "Y" for yes, "N" for no, explain where needed)
Y N 1. Had sexual relations will, anyone? (list first name and age)
(a)_________________________________ (b)_________________________________
Y N 2. List the locations besides your horde where you've engaged in sexual activity.
(a)_________________________________ (b)_________________________________
Y N 3. Rented any X-rated movies, looked at pornographic magazines, been to any houses of prostitution or adult book/sex type stores?
Y N 4. Had any sexual contact with animals?
Y N 5. Had any kind of contact with any of your victims (direct, phone, letters or messages of any kind)?
Y N 6. Have you masturbated? (When, where, most number of times in 1 day)
(a)_________________________________ (b)_________________________________ (c)_________________________________
Y N 7. Do you ever think or fantasize about any of your victims while masturbating?
Y N 8. Had any kind of contact with children or persons under 18 that would violate your probation or conditions of treatment?
Y N 9. Does your group treatment program know of all persons you've had sexual contact with since your last examination?
Y N 10. Engaged in any sexual activity with the person(s) listed above that the groupwould consider sexually improper? (Use of physical force, fantasies, trickery, etc.)
Y N 11. Lied or misrepresented any important information in treatment?
Y N 12. Done anything at all of an improper sexual nature that the group would disapprove of? (Besides what's already on this form) Explain fully.
________________________________________________________ ________________________________________________________ ________________________________________________________
Y N 13. Left the state without permission? Explain if "YES" answers.
________________________________________________________ ________________________________________________________ ________________________________________________________
Y N 14. Been with anyone when they committed any criminal act of any kind?
Y N 15. Stolen anything at all? (Shoplifting, from work, etc.)
Y N 16. Had any alcoholic beverage to drink? (When-Where-How much)
Y N 17. Seen illegal drugs being used or in the possession of anyone else?
Y N 18. Been present or took part in any kind of drug transaction?
Y N 19. Used any illegal drug yourself?
Y N 20. Used anyone else's prescription medication?
Y N 21. Been contacted by the police for anything?
Y N 22. Committed any minor traffic violations you weren't caught for?
Y N 23. Committed any kind of "general law" type violation for which you could have received a ticket or been arrested? (Bad checks, assault, criminal mischief, fish and game, weapons violations, littering, etc.)
Y N 24. Done anything else we should talk about that could violate probation?
I have told the absolute truth on this treatment questionnaire form:
Signature: _________________________________________________________________
