Home Page > Reading Room
This document was obtained by under the California Public Records Act.



                                  (Print name)

Whereas I,                                                desire employment as a                                                for the County of Los Angeles.

I understand that I will undertake and complete a polygraph examination in order to be considered for employment as a                                                for the County of Los Angeles.

I understand the Polygraph Examiner will conduct the examination in accordance with the limitations imposed by the Americans with Disabilities Act. The Act prohibits the Polygraph Examiner from asking questions about my medical condition or past medical history. This prohibition prevents the examiner from being able to assess whether I can safely take the examination and that [sic] the examination may be rescheduled to allow me to consult with my physician.

I understand the polygraph examination can be stressful and I assume any and all risks associated with this examination.

I understand the polygraph procedure involves the attachment of several components for the purpose of monitoring responses, and I consent to have those components attached to me.

I understand that all questions to be asked on the polygraph test will be reviewed with me in advance, and I am free to stop the test at any time I wish and for any reason. I agree to stop the procedure immediately if I believe that anything being done, could be harmful to me, mentally or physically.

I understand that during the polygraph examination, any or all of the pre-examination interview, examination, post-test interview or conversation may be audio and/or video recorded.

I agree to release the Polygraph Examiner conducting the polygraph examination, The County of Los Angeles, its officers, agents and employees from any and all liability in connection with this test and for the release of information and opinions to my background investigator and any and all other persons or parties interested therein.

Having read the above, I hereby voluntarily agree to submit to a polygraph examination.


Signed                                                                                             Dated                                              

Polygraph Examiner or L.A.S.D. Representative                                                 Date                     

Forms.pm97.26a_pre-offer_waiver.wpd Rev. 7/99

Transcription and HTML by Home Page > Reading Room