Correctional Officer Web format Example

ID NUMBER
OMB No. XXXX-XXXX Exp Date: XX/XX/XXXX

Background
1. What is your gender?
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Female

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Male

2. Are you currently married, widowed, divorced, separated, never married, or living with a partner?
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Married

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Widowed

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Divorced

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Separated

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Never married

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Living with a partner

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Don't know

3. What is the highest grade of school you completed, or the highest degree you have received?
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High school graduate

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GED or equivalent

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Some college, no degree

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Associate degree

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Bachelor's degree (example: BA, AB, BS, BBA)

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Master's degree (example: MA, MS, MEng, MEd, MBA)

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Professional school degree (example: MD, DDS, DVM, JD)

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Doctoral degree (example: PhD, EdD)

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Refused

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Don't know
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In your life, have you ever had any experience that was so frightening,
horrible, or upsetting that, in the past month, you...

Yes

No

13. Have had nightmares about it or thought about it when you did not want to?

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14. Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it?

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15. Were constantly on guard, watchful, or easily startled?

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16. Felt numb or detached from others, activities, or your surroundings?

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17. How much do you weigh without clothes or shoes? [ If you are currently pregnant , how much
did you weigh before your pregnancy?]
pounds
18. How tall are you without shoes?
{Enter height in feet and inches}
feet

inches

Employment
19. What is your current rank?
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Trainee (still in academy)

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Correctional Officer Recruit (probationary officer)

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Correctional Officer

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Senior Correctional Officer

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Sergeant

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Lieutenant

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Captain

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Chief or above

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Other (please describe):

20. How many years of correctional officer experience do you have in this facility?
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0-1 year

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2-5 years

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6-10 years

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11 or more years
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