(For Employees Only)

I, (name of employee), acknowledge that during the course of my employment on (specify date), I was asked a series of questions during normal business hours by investigators hired by XYZ Employer.

Before the examination, I received an explanation regarding its purpose and was advised that I had the right to leave the room at any time.

During the examination, I was free to leave.

I confirm that I suffered no harm as a result of the examination and that the examination was given in a reasonable manner in accordance with the procedures explained to me prior to the questioning.

I confirm that the following statements were made freely and voluntarily by me during the examination (specify):

I authorize that the results of any statements made by me be communicated and disclosed to third parties.  As a consequence of any remarks made by me during the examination, I understand that I may be disciplined leading up to or including immediate discharge by XYZ Employer.