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This document was obtained by under the California Public Records Act.




I,                                                             ,                                                              ,                                                   
   (Last Name)                                        (First Name)                                        (Middle Name)    (Please Print)

desire employment as a Police Officer for the Los Angeles Police Department and understand I must complete a polygraph examination in order to be considered for this position.

I understand that there are numerous physical or psychological factors, which could affect a polygraph examination. Factors that may influence the polygraph examination include: menstrual cramping, pregnancy, paralysis, recent surgery, cardiovascular ailments, respiratory problems, blood pressure conditions, medication, emotional disorders, severe pain, fatigue, or hunger, alcohol or drugs used in the last 24 hours. It is strongly suggested that if an applicant is concerned about an existing condition, they should consult with their personal physician well in advance of the scheduled polygraph examination.

The Polygraph Examiner will administer the examination in accordance with the limitations imposed by the Americans with Disabilities Act. This Act prohibits the Polygraph Examiner from asking questions about medical and psychological conditions. Police Officer applicants are not required to disclose any of the aforementioned factors. Due to this prohibition, the Polygraph Examiner is prevented from being able to assess whether it would be recommended to undergo a polygraph examination.

A polygraph examination can be stressful, and I assume all associated risks. A polygraph examination involves the attachment of several components for the purpose of monitoring physiological responses, and I consent to having those components attached to me. All questions to be asked during the polygraph examination will be reviewed in advance, and I have the right to terminate the examination at any time.

I agree to release the Polygraph Examiner administering the polygraph examination, the City of Los Angeles, Los Angeles Police Department, its officers, agents and employees, from any liability associated with this examination. I acknowledge that the polygraph examination results will be forwarded to Los Angeles Police Department Investigative Section personnel and City Personnel Department personnel.

Having read and understood the foregoing, I hereby voluntarily agree to submit to a polygraph examination. You have the right to consult an attorney regarding this waiver.


Applicant signature                                                                                           Date                                              

Polygraph Examiner                                                                                           Polygraph file                            

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