PFPA Form 1410 Employer Reference Questionnaire

OMB No. xxxx-xxxx
OMB approval expires
XXXXX XX XXXX

PENTAGON FORCE PROTECTION AGENCY
EMPLOYER REFERENCE QUESTIONNAIRE

The public reporting burden for this collection of information, xxxx-xxxx, is estimated to average 10 minutes per response , including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden
estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected].
Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if
it does not display a current valid OMB control number.

Privacy Act Notice
Pentagon Force Protection Agency will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
5 U.S. Code 552a for routine uses (i.e., information verifying an applicant’s employment may be disclosed to a prospective Agency that require information obtained in the
completion of this form to help in the determination as to the individual’s fitness for federal employment in the field of law enforcement) as identified in the system of
records notice at OPM/GOVT-5 system of records at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article- View/Article/570737/opmgovt-5/. Your
obligation to respond is voluntary, but failure to provide requested information could impede processing.

The Pentagon Force Protection Agency (PFPA) is considering
for a position with the
PFPA. Your name and agency were provided as a current or former employer by the individual listed above. We
would appreciate your input regarding this individual’s work history. Your assistance is sincerely appreciated.
1. Employer
a. Supervisor Title/Name:
b. Place of Employment:
c. Dates of Employment:

2. Work History (Please respond to all questions listed below and indicate N/A if a question is not relevant.)
a. Is the above named individual currently employed with your agency?

Yes

No

b. What is his/her job title?
c. What are their daily duties and responsibilities?

d. How long have you supervised the applicant (include dates of supervision)? Please provide names and contact
information for any past and/or additional supervisors.

e. What can you tell me about the employee’s attitude toward the job?

f. Does the employee have a problem reporting to work on time?

g. How much supervision does this person require to complete an assignment?

PFPA FORM 1410, April 2018

FOR OFFICIAL USE ONLY-PRIVACY SENSITIVE

Any misuse or unauthorized disclosure can result in both civil and criminal penalties.

h. What are some of the individuals’ strong points, and what areas do they need improvement?

i. Has it ever been necessary to initiate any disciplinary action against this person?

j. How was this person’s performance when employed with your agency? Please rate on a scale of 1-10. 10 being
EXCELLENT and 1 being UNSATISFACTORY.

k. Would you rehire this person? If not please explain.

l. Based on your knowledge of this person, would you recommend them for employment as a Pentagon Force
Protection Agency?

3. Additional Remarks

4. Information Recorded By
a. Officer/Investigator Recording Information:

PFPA FORM 1410, April 2018

Date Information Taken:

Page 2
FOR OFFICIAL USE ONLY-PRIVACY SENSITIVE

Any misuse or unauthorized disclosure can result in both civil and criminal penalties.

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