Its just a scantron with asking the following:
1. How long have you known this person?
A) ____ years _____ months B) I don't know this person
2. My association with this person is/was as a:
A) Coworker B) Neighbor C) Friend D) Spouse E) Former Spouse F) Instructor G) Relative H) Other (explain)
3. On the average, I associate(d) with this person:
A) Daily B) Weekly C) Monthly D) Twice a Year E) Once Every Year or 2 D) Once in 3 or More Years
4. I last associated with this person:
A) 0-3 months ago B) 3-12 months ago C) 1-3 years ago D) 3-5 years ago E) 5+ years ago
5. Does the informaion on the front of this form concerning this person apear to be correct?
A) yes B) No-it appears to be incorrect or incomplete (explain)
6. Do you have any reason to question this person's honesty or trustworthiness?
A) No B) Yes (explain) C) I do not know this person well enough to respond D) I wish to discuss the adverse information I have
7. Do you ahve any adverse information about this person's employement, residence or activities concering:
Violations of the Law, Financial Integrity, Abuse of Alcohol and/or Drugs, Mental or Emotional Stability, General Behavior or Conduct, Other Matters (explain)
(There is a yes or no bubble next to each one of those)
8. Additional information which you feel may have a bearing on this person's suitability for government employment or security clearance. This space may be used for derogatory as well as positive information.
9. Do you recommend this person for goverment security clearance or employement?
A) Yes B) No (explain) C) I don't know this person well enough to make a recommendation.