CORRECTIONAL OFFICER / PRIMARY WORKER / KIMISINAW PRE-EMPLOYMENT QUESTIONNAIRE

The information collected in this form may be extremely personal and sensitive.

To protect your privacy, and to ensure confidentiality, it is strongly recommended that you complete this questionnaire in private.

This HTML page is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to submit a form, you must use only the Printable PDF version.

Applicant Surname:

Applicant Given Name(s):

Date of Birth (YYYY-MM-DD):

Gender:

Mailing Address (Street address, city, province, postal code):

Telephone No. 1:

Telephone No. 2:

List All E-Mail Addresses you have/use:

List All Social Networking and Blogging User Name(s) you have/use:

List All Social Networking Site(s) and Blogs you are Registered with:

Proprietary Notice

This form is the property of Correctional Service Canada (CSC) and the Government of Canada. It is not to be reproduced or used for any purpose without the expressed written consent of CSC.

CSC shall not be responsible for the unauthorized application or use of this form. All rights reserved.

Pre-Employment Questionnaire

Before writing answers to the questions contained in this form, Applicants are advised to:

• carefully read the information and notices on page 1, 2 & 3;
• read, initial and sign the Declaration, Acknowledgment, and Consent on page 4; and
• follow the instructions listed on page 5.

The questions contained in this Pre-Employment Questionnaire pertain to your honesty, suitability, integrity and ethics.

CSC is not looking for flawless individuals, but looks for appropriately qualified applicants who reflect CSC's values and integrity.

Notice Regarding the Pre-Employment Questionnaire

Your decision to complete the Pre-Employment Questionnaire must be voluntary, based on your desire to pursue a career as a Correctional Officer / Primary Worker/Kimisinaw. You may withdraw or stop the application process at any time. You may refuse to provide answers to any or all of the questions contained in the Pre-Employment Questionnaire. However, such a refusal may result in your elimination from the recruitment process.

Answer the questions contained in the Pre-Employment Questionnaire accurately, completely, thoroughly, and honestly to the best of your knowledge and belief. An incomplete Pre-Employment Questionnaire may result in your elimination from the recruitment process.

You are not obliged to provide any information in the Pre-Employment Questionnaire that relates to a conviction for which a pardon has been received or a conviction that was processed pursuant to the Young Offenders Act (R.S.C., 1985, c. Y-1, now repealed) or the Youth Criminal Justice Act (S.C., 2002, c.1).

You are under no obligation to disclose any information regarding a crime where you were a victim.

Deceit, dishonesty, or non-disclosure in any part of the application process may result in your elimination from the process and/or future employment at CSC. We may contact you directly to inquire about your responses to the questionnaire.

Notice Regarding the Collection and Use of Personal Information

CSC is collecting, on a voluntary basis, personal information on the Pre-Employment Questionnaire to assist in determining the suitability and reliability of the applicant, and to contribute to suitability screening. The information requested is essential for making these employment determinations.

The information collected is protected and managed in conformity with the provisions of the Privacy Act (R.S.C., 1985, c. P-21).

The information collected will be stored by CSC and may be disclosed pursuant to the Privacy Act. Under this Act, individuals have the right to protection of, access to, and correction of their personal information.

Notice Regarding Prior Serious Criminal Offences and Serious Risk to the Safety of Others

The information you provide during the process is collected by CSC for the purposes of an employment application, and suitability screening. However, if an applicant admits to having committed a serious and undetected criminal offence, or is deemed to pose a serious risk to the safety of others, CSC may use or disclose specific information for a law enforcement or public safety purpose. While cases of such use and disclosure outside of the process are rare and exceptional, CSC strongly discourages any applicant from completing the Pre-Employment Questionnaire if you believe this Notice applies to you.

If you admit to having committed one or a number of serious criminal offence(s) on the Pre-Employment Questionnaire, or in light of the information provided on the Pre-Employment Questionnaire, you are deemed to pose a serious threat to others, be advised that the information may be disclosed to entities with lawful authority to collect such information (e.g. police of jurisdiction or child protection agency).

You are also advised that such disclosures could lead to incident reports being entered into police databases, which could impact future employment, volunteer opportunities, or other activities that require security screening (e.g. employment with schools, banks, etc.).

Such disclosures could also lead to an investigation, arrest, charge(s), criminal prosecution, conviction, and ultimately, imposition of a sentence.

Declaration, Acknowledgement and Consent

Should you have any questions concerning what you have read in the preceding pages please contact CSC's Enhanced Suitability Screening Unit at GEN-NHQ-ESS-VAA@CSC-SCC.gc.ca to clarify before proceeding any further.

Declaration, Acknowledgement and Consent	Applicant Initials
I, the undersigned, have read and understand the information and notices on page 1, 2 and 3 of this Pre-Employment Questionnaire.
I complete this Pre-Employment Questionnaire voluntarily, based on my desire to pursue a career as a Correctional Officer/Primary Worker/Kimisinaw.
I declare that I will provide, in this Pre-Employment Questionnaire, information that is up-to-date, accurate, complete, and honest, to the best of my knowledge and belief.
I understand that I may amend my answer(s) to any question(s) in the Pre-Employment Questionnaire at any time prior to the scheduled date for an interview by contacting the Enhanced Suitability Screening Unit.
I understand that I do not have to include any information in this Pre-Employment Questionnaire that relates to a conviction for which a pardon has been granted, or a conviction that was processed pursuant to the Young Offenders Act or Youth Criminal Justice Act.
I understand that if I admit to having committed one or a number of serious criminal offence(s), in this Pre-Employment Questionnaire, actions could be taken which could lead, ultimately, to the imposition of a sentence.
I understand that if in light of the answers provided in this Pre-Employment Questionnaire, I am deemed to pose a serious risk to the safety of others, actions could be taken which could lead, ultimately, to the imposition of a sentence.
I consent to my personal information being collected, used, and disclosed for the purposes identified on pages 1, 2, 3 of this Pre-Employment Questionnaire.
I consent to my personal information being used for suitability screening.
I consent to a personal credit check (financial assessment including credit records check).

 

Name of Applicant (print)

 

Signature of Applicant

 

Date (YYYY-MM-DD)

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Section A - Personal History & Employment

1. Have you ever changed your name, used or gone by any other name(s) or used variations of your existing name?

• Yes
• No

If yes, provide details:

Name:
Details of Name Change:

2. Do you have now or have you in the past five years had a relationship with any offender(s)/inmate(s) incarcerated or on parole?

• Yes
• No

If yes, provide details:

Name of Offender / Inmate:
Date of Relationship Start:
Duration of Relationship:
Nature of Relationship:
Address:

3. If yes to question 2, did you enter into the relationship while fully aware of their past history?

• Yes
• No

4. Do you have now or have you in the past five years had a relationship with anyone with a criminal record?

• Yes
• No

If yes, provide details:

5. List the names of everyone you have lived with at each address over the past five years.

Complete Address:
Relationship
Cohabitant’s Names:

6. Have you ever applied for a position within the Correctional Service of Canada previously?

• Yes
• No

If yes, provide details:

Position Applied for:
Date:
Details:

7. List your employer(s) for the past five years, starting with your most current employer.

Name of Employer:
Address:
Position/Title:
Start Date (YYYY-MM-DD)
End Date (YYYY-MM-DD)

8. Have you ever had employment terminated, been fired, dismissed, or asked to resign from a job for any reason?

• Yes
• No

If yes, explain:

Status: Terminated, Fired, Dismissed, Resigned
Name of Employer
Date (YYYY-MM-DD)
Details:

9. Have you ever cheated on any form of examination or plagiarized another person's work? (includes both education and/or employment and your application to CSC)

• Yes
• No

If yes, explain:

10. Do you own or rent your residence?

• Own
• Rent

If you rent, provide the name(s) of your landlord?

Name:
Address:

11. List the name(s) of your family member(s) (parents, siblings, spouse/partner, children).

Name:
Relationship:
Address:

12. Have you visited a foreign country or lived outside Canada in the past five years?

• Yes
• No

If yes, provide details

Country visited:
Date of Visit (YYYY-MM-DD):
Purpose of Visit:
Duration of Visit:

13. Do you hold multiple citizenships?

• Yes
• No

If yes, for what countries and for what reason/purpose:

Country of Citizenship:
Date of Issuance:
Reason/Purpose for Citizenship:

14. What high school(s) did you attend, and during what years?

Name of School:
Start Date (YYYY-MM-DD):
End Date (YYYY-MM-DD):
Years Attended:
City:
Reason for Change:

15. What college(s)/university(ies) did you attend, and during what years?

Name of College/University:
Start Date (YYYY-MM-DD)
End Date (YYYY-MM-DD)
Years Attended:
City:
Reason for Change:

16. Are you currently or have you ever been a member of a club(s), organization(s) or association(s) (professional or personal) and/or contributed support to (financially or otherwise) in Canada or elsewhere?

• Yes
• No

If yes, provide details:

Name of Club/Organization/Association:
Membership Start Date (YYYY-MM-DD)
Membership End Date (YYYY-MM-DD)
Address:
Role/Position in the Club/Organization/Association:

17. What activities do you do in your free time?

18. Are you currently or have you ever been self-employed?

• Yes
• No

If yes, provide details and advise if you are still involved with the company/business:

Name of Company/Business:
Civic Address:
Website Address:
Provincial/ Federal Registration Number:
Involvement:

19. Are you currently or have you ever been a Director, CEO, CFO, President, Treasurer, Secretary, Shareholder, or Board Member of a company/business?

• Yes
• No

If yes, provide details and advise if you are still involved with the company/business:

Name of Company/Business:
Civic Address:
Phone Number(s):
Website:
Position:
Time Period:

Section B - Driving History

20. Have you ever had your driver's license revoked, suspended, or placed on a probationary status?

• Yes
• No

If yes, explain:

Status: Revoked, Suspended, Probation
Date of Reinstatement (YYYY-MM-DD)
Details:

21. Do you have any outstanding motor vehicle/driving violations or unpaid traffic tickets, including parking tickets?

• Yes
• No

If yes, provide details:

Violations:
Date (YYYY-MM-DD)
Details:

Section C - Financial

22. Do you gamble? (Including lottery, casinos, online gaming, scratch tickets, etc.)

• Yes
• No

If yes, explain:

Method and / or Casino Name:
Frequency of Gambling:
Location:
Last Purchase/Visit (YYYY-MM-DD):

23. How much money have you spent, wagered, lost or won in the last five years as a result of gambling?

Total Amount:
Spent:
Wagered:
Lost:
Won:

24. Do you presently owe any gambling debts (including credit card debt incurred due to gambling)?

• Yes
• No

If yes, explain:

Amount:
Details:

25. Have you ever placed a wager/bet with a professional bookmaker (bookie)?

• Yes
• No

If yes, where, for what reason and what was your bet:

Amount:
Name:
Location:
Last Purchase/Visit:

26. Have you ever declared bankruptcy?

• Yes
• No

If yes, explain:

Amount:
Date:
Province:
Details:

27. Are you currently having any difficulties meeting your financial obligations?

• Yes
• No

If yes, explain:

Obligation: Mortgage, Hydro, Water, Cable/Satellite, Gas, Phone, Insurance, Property Tax, Child Support, Alimony, Other/Explain
30 Days Past Due:
60 Days Past Due:
90 Days Past Due:
Details:

Section D – Alcohol

28. Which restaurant, bars, social clubs, private clubs and nightclubs do you frequent and for what purpose?

Name of Establishment:
Address:
Frequency of Visits:
Purpose of Visits:
Average Amount Alcoholic Drinks Consumed Per Visit in ounces / type:

29. Have your experiences with alcohol ever caused you problems at work or otherwise?

• Yes
• No

If yes, explain:

Place: Work, Other
Date:
Details:

Section E – Drug Use

30. Have you ever used or experimented with any illegal drugs?

• Yes
• No

If yes, provide requested information for each drug and explain circumstances of use below:

Drug: Acid/LSD, Cocaine/Crack, Ecstasy, Hash/Hash oil, Heroin, Mushrooms, Marijuana, Methamphetamine/Crystal Meth, Steroids, Other
Method and Frequency of Use:
Approximate Dates of Use (first time, last time):
Circumstance:
Means to Obtain Drugs:
Financial Outlay (How much do/did you spend on drugs on a monthly basis):

31. Have you ever abused or sold any pharmaceutical (prescription) drugs?

• Yes
• No

If yes, explain:

Drug: Demerol (Meperidine), Dilaudid (Hydromorphone), Fentanyl, Hydrocodone, Methadone, Morphine, Oxycodone, Oxycontin, Percocet, Percodan, Ritalin, Valium (Diazepam), Xanax, Other
Method and Frequency of Use:
Approximate Dates of Use (first time, last time):
Circumstance:
Means to Obtain Drugs:
Financial Outlay (How much do/did you spend on drugs on a monthly basis):

32. Have you ever obtained or purchased illegal drugs for the purpose of growing or manufacturing?

• Yes
• No

If yes, explain:

Activity: Purchased, Grown, Manufactured, Obtained
Date (YYYY-MM-DD):
Details:

33. Have you ever provided, sold or given illegal drugs to anyone?

• Yes
• No

If yes, explain:

Activity: Sold, Given
Date (YYYY-MM-DD):
Details:
Provided:

34. Do you associate with anyone who uses illegal drugs or do you frequent places where illegal drugs are being used?

• Yes
• No

If yes, explain:

Friends(s)/Establishment(s):
Date (YYYY-MM-DD):
Details:

Section F- Unlawful Sexual Activity

You are not obligated to disclose any information regarding a crime where you were the victim.

35. Have you ever travelled outside of Canada for the purpose of engaging in sexual activity with a person under the age of 18?

• Yes
• No

If yes, explain:

Date of Travel:
Country:
City:
Duration of Visit:

36. Have you ever solicited the services of a prostitute in Canada or abroad?

• Yes
• No

If yes, explain:

Date (YYYY-MM-DD):
Country:
City:
Name of Massage Parlour/Escort Service/Bawdy House:

37. Have you ever knowingly viewed, possessed, distributed and/or engaged in the making of child pornography? (For the purpose of this questionnaire, our definition of child pornography is a young person not developed and/or engaged in a sexual act).

• Yes
• No

Section G - Involvement with Law Enforcement

38. Have you ever been refused, suspended or fired from any job with the military, a police service, or an intelligence service in Canada or any other jurisdiction?

• Yes
• No

If yes, explain:

Activity: Refused, Suspended, Fired
Date:
Details:

39. Have you ever had a court order issued against you?
(including search warrant, arrest warrant, peace bond, restraining order, protection order or restitution order)

• Yes
• No

If yes, explain:

Court Order: Search Warrant, Arrest Warrant, Peace Bond, Restraining Order, Protection Order, Restitution Order
Date:
Details:

40. Have you ever been questioned by a law enforcement agency as a witness or a suspect?

• Yes
• No

If yes, explain:

Witness:
Date:
Details:

Suspect:
Date:
Details:

41. Have you ever been involved in a verbal or physical altercation with a police officer?

• Yes
• No

If yes, explain:

42. Have you ever been refused a gun permit or had a permit revoked?

• Yes
• No

If yes, explain:

Gun Permit Refused:
Date (YYYY-MM-DD):
Details:

Gun Permit Revoked:
Date:
Details:

43. Is there any reason, legal or otherwise, why you cannot carry or be licensed to carry a firearm?

• Yes
• No

If yes, explain:

44. Have you ever pointed a firearm at yourself or another person?

• Yes
• No

If yes, explain:

45. Have you ever injured yourself or another person with a firearm or weapon?

• Yes
• No

If yes, explain:

46. Have you or are any of your family members or friends ever been associated with any gang, criminal group/individual, terrorist group/individual, militant group or other subversive organization, or have loyalties to any of these groups?

• Yes
• No

If yes, explain:

Group: Gang, Criminal Group/Individual, Terrorists Group/Individual, Militant Group, Other Subversive Organization
Name of the Group/Individual:
Time Period (YYYY-MM-DD):
Relationship to You:
Details:

47. Have you ever been convicted of a criminal offence for which you have not been granted a pardon?

• Yes
• No

If yes, provide details:

Charge(s):
Date of Conviction (YYYY-MM-DD):
City/Province/State/Country:
Details & Name of Police Force:

Section H – Other

48. Have you ever been involved in the research, building or use of a bomb or explosive devices, either alone or acting with others, which was not a requirement of your employment or studies?

• Yes
• No

Section I - Computers and Technology

49. Have you ever hacked and/or attempted to gain unauthorized access into any computer system, business, private, Canadian or foreign government systems, which was not a requirement of your employment or studies?

• Yes
• No

50. Have you ever purposely caused damage, destroyed or corrupted data or hardware on a work site computer system?

• Yes
• No

This Pre-Employment Questionnaire is not completed until you have read, understood and signed, and dated the Final Declaration, Acknowledgement, and Consent. If delivered without your printed name, signature, and date on this page, this Pre-Employment Questionnaire will be returned to you, delaying your application process.

The completed and signed Pre-Employment Questionnaire must be returned by mail in a sealed envelope to the attention of:

Enhanced Suitability Screening Unit
340 Laurier Ave West
Ottawa, ON K1A 0P9

Printable Version