Polygraph Consent

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Polygraph Examination Consent Form

I, {{employee_full_name}}, hereby acknowledge that I have been informed by {{company_name}} ('the Company') of the Company's intention to conduct a polygraph examination as part of an investigation into {{reason_for_examination}}.

Voluntary Consent

I understand that my participation in this polygraph examination is entirely voluntary and that I have the right to refuse to participate. I further understand that my refusal to participate will not automatically result in disciplinary action against me, but that the Company may draw reasonable inferences from such refusal in the context of the ongoing investigation.

Purpose of Examination

I understand that the polygraph examination is being conducted for the purpose of assisting in the investigation of {{detailed_purpose_of_examination}}. I confirm that I will be questioned solely in relation to the relevant incident(s) and that no questions will be asked regarding my private life, religious beliefs, political affiliations, or sexual orientation.

Disclosure of Rights

I confirm that I have been made aware of the following rights:

a. The right to consult with legal counsel or a trade union representative prior to the examination.

b. The right to have a representative, chosen by me, present during the examination, provided that such presence does not interfere with the examination process.

c. The right to interrupt the examination at any time.

d. The right to view and review the questions that will be asked prior to the examination.

e. The right to a copy of the polygraph report, should one be generated and concluded.

Confidentiality

I understand that the results of this polygraph examination will be treated with strict confidentiality and will only be disclosed to those individuals within the Company who have a legitimate need to know for the purpose of the investigation. I consent to the disclosure of the results to appropriate internal company personnel and, if applicable, to external legal counsel or law enforcement agencies as required by law or as deemed necessary by the Company for the pursuit of justice.

Declaration

I declare that I am voluntarily consenting to undergo the polygraph examination without any undue influence, coercion, or promise of reward. I confirm that I am in a fit mental and physical state to undergo the examination.

Date and Time of Examination

The polygraph examination is scheduled to take place on {{date_of_examination}} at {{time_of_examination}} at {{location_of_examination}}.

Signature Block

___________________________

Employee Full Name: {{employee_full_name}}

Employee ID: {{employee_id}}

Date: {{date}}

___________________________

Witness Full Name: {{witness_full_name}}

Date: {{date}}

___________________________

Company Representative Full Name: {{company_representative_full_name}}

Position: {{company_representative_position}}

Date: {{date}}