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Neighborhood Check Questionnaire
1
Your Details
2
Questionnaire
Instructions
We are conducting a Pre-Employment Background Investigation on your neighbor for a position of public trust with a Public Safety Agency and attempted to contact you unsuccessfully. We respectfully request that you complete the questionnaire below are your earliest convenience. Your anticipated assistance in this matter is greatly appreciated. Please don’t hesitate to contact us if you have any questions or concerns.
Your Name
(Required)
First
Last
Your Phone Number
(Required)
Your Email Address
(Required)
Your Street Number
(Required)
Your Street Name
(Required)
Unit Number (if necessary)
Questionnaire
Please answer the questionnaire about your neighbor truthfully and honestly. Throughout the questionnaire we will refer to your neighbor as the
Applicant
.
Applicant Name
(Required)
First
Last
Applicant Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
How well do you know the Candidate?
(Required)
Not At All
In Passing
Somewhat
Well
Very Well
Do you know the candidate well enough to complete a Personal Reference Questionnaire?
(Required)
No
Yes
Is the Candidate friendly and/or helpful to others?
(Required)
No
Yes
Unknown
If No, please describe:
(Required)
Are you aware of any unethical or immoral behavior by the Candidate?
(Required)
No
Yes
Unknown
If Yes, please describe:
(Required)
Have you ever suspected any illegal activity by the Candidate?
(Required)
No
Yes
Unknown
If Yes, please describe:
(Required)
Has law enforcement ever responded to the Candidate's residence?
(Required)
No
Yes
Unknown
If Yes, please describe:
(Required)
Has the Candidate caused any problems in the neighborhood?
(Required)
No
Yes
Unknown
If Yes, please describe:
(Required)
Are you aware of any circumstances that might disqualify the Candidate from a position of public trust?
(Required)
No
Yes
Unknown
If Yes, please describe:
(Required)
Do you know the Candidate well enough to recommend them for a position of public trust?
(Required)
No
Yes
Unknown
If Yes, please describe:
(Required)
May we contact you with any further questions regarding the Candidate?
(Required)
No
Yes
Can you provide any additional references who know the Candidate?
(Required)
No
Yes
Please provide the full name, telephone, and email address of the reference(s):
(Required)
You can add additional references by selecting the ➕ icon to the right of the Telephone text box. You can remove a reference by selecting the ➖ icon that will appear when you’ve added additional references.
Full Name
Email
Telephone
Add
Remove
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