CONSENT FOR POLYGRAPH EXAMINATION

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP86B00338R000300400013-3
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 5
• Document Creation Date: December 21, 2016
• Document Release Date: August 28, 2008
• Sequence Number: 13
• Content Type: FORM

Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
CONSENT FOR POLYGRAPH EXAMINATION
(Applicant or Staff-Like Access)
I, , consent to polygraph
testing administered by examiners of the Central Intelligence Agency. I am under consideration for em-
ployment with the CIA or for staff-like access to Agency information or facilities. I understand that poly-
graph testing and periodic retesting is required as a precondition for such employment or staff-like
access.
The procedures that are to be followed during the examination have been explained to me, and I
am aware that the procedures will include the use of sensors to record my physiological responses to
questions. I understand that the questions to be asked during the examination will be limited to those
necessary to resolve security issues, as approved by the Director of Central Intelligence, such as loyalty,
compromise of classified information and counterintelligence, falsification of personal history documents
and vulnerability to blackmail, and that the questions will be reviewed with me, at least in general, prior
to the examination.
I am aware that information obtained in the course of the polygraph examination will be strictly
controlled within the Central Intelligence Agency and may not be released outside of the Central
Intelligence Agency except when necessary in the interest of national security as determined by the Di-
rector or Deputy Director of Central Intelligence, or as provided below.
I have been further advised that any information relating to violations of law will be reported to
the Attorney General as required by Section 535 of Title 28 of the United States Code and Executive Or-
der 12036 or its successors, and also may be reported to appropriate law enforcement or other
government agencies for administrative, investigative or legal action. I have also been advised of my
rights against self-incrimination under the Fifth Amendment to the Constitution of the United States. I
also understand that the session with the polygraph examiner may be monitored and recorded for the
purpose of clarity and accuracy.
I have read the foregoing and understand its import fully.
IN WITNESS WHEREOF, I place my signature below, this day of 19
The above was read and signed in my presence this day of
m 42 1139a ossoEn PREVIOUS EDITIONS
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 Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
CONSENT FOR POLYGRAPH EXAMINATION
(Probationary Employee)
I, , an employee of the
Central Intelligence Agency, consent to polygraph testing as part of the Reinvestigation Program
pending conversion to staff employment status. I understand that periodic polygraph testing is required
as a condition of continued employment.
The procedures that are to be followed during the examination have been explained to me, and I
am aware that the procedures will include the use of sensors to record my physiological responses to
questions. I understand that the questions to be asked during the examination will be limited to those
necessary to resolve security issues, as approved by the Director of Central Intelligence, such as loyalty,
compromise of classified information and counterintelligence, falsification of personal history documents
and vulnerability to blackmail, and that the questions will be reviewed with me, at least in general,prior
to the examination.
I am aware that information obtained in the course of the polygraph examination will be strictly
controlled within the Central Intelligence Agency and may not be released outside of the Central
Intelligence Agency except when necessary in the interest of national security as determined by the Di-
rector or Deputy Director of Central Intelligence, or as provided below.
I have been further advised that any information relating to violations of law will be reported to
the Attorney General as required by Section 535 of Title 28 of the United States Code and Executive or-
der 12036 or its successors, and also may be reported to appropriate law enforcement or other
government agencies for administrative, investigative or legal action. I have also been advised of my
rights against self-incrimination under the Fifth Amendment to the Constitution of the United States. I
also understand that the session with the polygraph examiner may be monitored and recorded for the
purpose of clarity and accuracy.
I have read the foregoing and understand its import fully.
IN WITNESS WHEREOF, I place my signature below, this day of 19
The above was read and signed in my presence this day of 19
FORM
1139f ossoure.Revious mnow
Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
 Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
CONSENT FOR POLYGRAPH EXAMINATION
(Employee Reinvestigation)
I, , an employee of the
Central Intelligence Agency, consent to polygraph reexamination as part of the Reinvestigation Program.
I understand that periodic polygraph testing is required as a condition of continued employment.
The procedures that are to be followed during the examination have been explained to me, and I
am aware that the procedures will include the use of sensors to record my physiological responses to
questions. I understand that the questions to be asked during the examination will be limited to those
necessary to resolve security and counterintelligence issues as approved by the Director of Central
Intelligence, such as loyalty, compromise and unauthorized storage of classified information, and
counterintelligence, and that the questions will be reviewed with me, at least in general, prior to the
examination.
I am aware that information obtained in the course of the polygraph examination will be strictly
controlled within the Central Intelligence Agency except when necessary in the interest of national secu-
rity as determined by the Director or Deputy Director of Central Intelligence.
I have been further advised that any information relating to violations of law will be reported to
the Attorney General as required by Section 535 of Title 28 of the United States Code and Executive Or-
der 12036 or its successors, and also may be reported to appropriate law enforcement or other
government agencies for administrative, investigative or legal action. I have also been advised of my
rights against self-incrimination under the Fifth Amendment to the Constitution of the United States. I
also understand that the session with the polygraph examiner may be monitored and recorded for the
purpose of clarity and accuracy.
I have read the foregoing and understand its import fully.
IN WITNESS WHEREOF, I place my signature below, this day of 19
The above was read and signed in my presence this day of
.M 1139 o.soune .REViotu EomoNs
Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
 Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
CONSENT FOR POLYGRAPH EXAMINATION
(Specific Issue)
I, , an employee of ' the
Central Intelligence Agency, consent to a polygraph examination which has been approved by the
Director of Security or his delegate, to resolve or clarify the security issues in question.
The procedures that are to be followed during the examination have been explained to me, and I
am aware that the procedures will include the use of sensors to record my physiological responses to
questions. I understand that the questions to be asked during the examination will be limited to those
necessary to resolve security issues in question as defined by the Director of Security and that the ques-
tions will be reviewed with me, at least in general, prior to the examination.
I am aware that information obtained in the course of the polygraph examination will be strictly
controlled within the Central Intelligence Agency and may not be released outside of the Central
Intelligence Agency except when necessary in the interest of national security as determined by the Di-
rector or Deputy Director of Central Intelligence, or as provided below.
I have been further advised that any information relating to violations of law will be reported to
the Attorney General as required by Section 535 of Title 28 of the United States Code and Executive Or-
der 12036 or its successors, and also may be reported to appropriate law enforcement or other
government agencies for administrative, investigative or legal action. I have also been advised of my
rights against self-incrimination under the Fifth Amendment to the Constitution of the United States. I
also understand that the session with the polygraph examiner may be monitored and recorded for the
purpose of clarity and accuracy.
I have read the foregoing and understand its import fully.
IN WITNESS WHEREOF, I place my signature below, this day of 19
The above was read and signed in my presence this day of 19
. 1139e aumm PREV10US imsom
Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
 Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3
CONSENT FOR POLYGRAPH EXAMINATION
(Access to Agency Information)
I, , consent to polygraph
testing administered by examiners of the Central Intelligence Agency. I am under consideration for ac-
cess or continued access to certain Agency information. I understand that polygraph testing is now re-
quired by CIA as a precondition for such access or continued access.
The procedures that are to be followed during the examination have been explained to me, and I
am aware that the procedures will include the use of sensors to record my physiological responses to
questions. I understand that the questions to be asked during the examination will be limited to those
necessary to resolve security issues, as approved by the Director of Central Intelligence, such as loyalty,
compromise of classified information and counterintelligence, and that the questions will be reviewed
with me, at least in general, prior to the examination.
I am aware that information obtained in the course of the polygraph examination will be strictly
controlled within the Central Intelligence Agency and may not be released outside of the Central
Intelligence Agency except when necessary in the interest of national security as determined by the Di-
rector or Deputy Director of Central intelligence, or as provided below.
I have been further advised that any information relating to violations of law will be reported to
the Attorney General as required by Section 535 of Title 28 of the United States Code and Executive Or-
der 12036 or its successors, and also may be reported to appropriate law enforcement or other
government agencies for administrative, investigative or legal action. I have also been advised of my
rights against self-incrimination under the Fifth Amendment to the Constitution of the United States. I
also understand that the session with the polygraph examiner may be monitored and.recorded for the
purpose of clarity and accuracy.
I have read the foregoing and understand its import fully.
IN WITNESS WHEREOF, I place my signature below, this day of 19
The above was read and signed in my presence this day of .
Fow
m 1139b ossoure newous em oNs
Approved For Release 2008/08/28: CIA-RDP86B00338R000300400013-3