Victim/Accuser's Statement & Case Information 2020

ACCUSER/VICTIM'S FORM: Case Information Form
This form is STEP 2 in the polygraph and/or eyedetect exam process. Do not complete this form until you have a confirmed appointment date.

This form is for the ACCUSER/VICTIM complete ONLY. This form may not be completed by anyone else other than the ACCUSER/VICTIM.

This form is compromised of 11 different sections, A-J.

A: Exam Verification

B: Subject's Information

C: Accuser's Information

D: Disclaimers

E: Statement Collection

F: Question Submission

G: Evidence Collection (Option to Upload Files)

H: Credibility Assesment

I: Policies & Notices

J: Signature & Form Submission

Depending upon your responses, this form may take anywhere from 20 minutes to 45 minutes to complete.

Section A: Verify Your Exam(s) is Already Scheduled
Please verify that their is a confirmed appointment.
What is the confirmed date of the scheduled polygraph and/or EyeDetect exam? *

Month Day Year
This was the date you selected in Step 1 when you booked and paid for your exam online.
What is the time of the polygraph and/or EyeDetect exam?

: Hour Minutes AM/PM Option
What type of exam(s) is scheduled? *
This is the service you paid for when you scheduled your exam online during Step 1.
Are you the person taking the exam?

Yes No

Section B: SUBJECT'S INFORMATION
SECTION B: THE SUBJECT'S INFORMATION

The Subject is the person taking the polygraph or EyeDetect exam.
Subject's Full Legal Name *
The Subject is the person taking the exam.
What name does the Subject go by (Nickname/street name) ? *
The Subject is the person taking the exam.
Subject's Address
Subject's Primary E-mail address *
Subject's Secondary E-mail address *
Subject's Phone Number *
Subject's Alternative Phone Number
List ALL social media accounts that the Subject has to include any secret, hidden, undisclosed or alias accounts along with Screen Names and the platforms:
Subject's Date of Birth *

Month Day Year
The Subject must be at least 16 years of age.
What is your relationship to the Subject? *
In other words, who are you?
Does the Subject have any medical or mental health conditions that could prevent them from safely and successfully taking a polygraph and/or EyeDetect exam? *

No Yes (Explain in the box below)
If you answered YES, please explain in detail in the box below.
Does the Subject take any medications that could effect the exam? *

No Yes (Explain in the box below)
If you answered YES, please explain in detail in the box below.
Has the Subject ever been arrested or convicted of a crime? If yes, please explain each arrest and charges in the space below. *

No Yes (Explain in the box below)
If you answered YES, please explain in detail in the box below. *

Section C: ACCUSER / VICTIM'S INFORMATION
SECTION C: THE ACCUSER/VICTIM'S INFORMATION

The Accuser or Victim is the person making the allegation against the Subject.
Accuser/Victim's Full Legal Name *
Accuser/Victim's Address
What is the Accuser/Victim's relationship to the Subject? *
In other words, who is the Accuser/Victim?
Accuser/Victim's Phone Number *
Accuser/Victim's Email *
example@example.com
Is the Accuser/Victim a minor? *

Yes No
May we contact the Accuser/Victim? *

Yes No
Take Photo: To verify that you, the Accuser/Victim are the person filling out this form, please take or upload a photo of yourself.

Section D: Lie Detector Test Notice and Disclaimer
SECTION D: LIE DETECTOR QUESTION LIMITATION NOTICE & DISCLAIMERS
Lie Detector Tests CAN NOT UNDER ANY CIRCUMSTANCE ask about any of the following:
- State of Mind
- Feelings/Emotions/Affections
- Thoughts
- Fantasies
- Desires
- Wants
- Daydreams
- Future Intentions
- Ideas
- Or any variation/synonym of the above
Questions CAN NOT be:
- Complex, compound or run-on sentances
- Be open ended questions
- Have multiple answers other than "Yes or No"
- Have any answer other than "Yes or No"
- Vague, diluted or non-specefic
All Questions are REQUIRED to Be:
- Specefic and Direct
- "Yes or No" only questions
- Based off facts or actions only
- Reasonable for the Subject to be able to truthfully answer
The Final Questions Asked on the Exam Will Be:
- The questions you submit serve as a guideline to help us understand what answers you are trying to obtain. However, ALL final questions asked on the exam WILL be written by the examiner to ensure they meet national standards and legal guidelines.
- The final questions will be written minutes prior to the exam to accomidate any admissions/confessions that may have been made prior to the exam during the interview. Any admissions/confessions made will be documented within the report.
- There will be 1-4 relevant questions asked on the polygraph exam and each of those relevant questions will relate back to one, single, specefic issue.
- There will be 1 and only 1 relevant question asked on the EyeDetect.
Read the statement below and then check the button to acknowledge that you read, understand, accept and consent to the following statement in regards to taking a lie detector test. *

I understand that all polygraph and/or EyeDetect exams conducted by Validate, LLC will cover ONE and ONLY ONE Single, Specific Issue per exam. I understand that all relevant questions asked on any exam by Validate, LLC will be directly related to the ONE Single, Specific issue being tested. I understand that the polygraph examiner and/or EyeDetect proctor will formulate, write and solely determine the specific questions that will be asked on any exam. I understand that 2 to 4 relevant questions may be asked on the polygraph exam. I understand that only 1 relevant question, which will be asked in a variety of different ways, will be asked on the EyeDetect exam. I understand that if I have multiple issues and/or more questions than is already included that I would need to purchase additional services for an additional fee. I understand that polygraph exams and EyeDetect exams may only test facts and specific actions. I understand that polygraph exams and EyeDetect exams may not test feelings, thoughts, emotions, fantasies, desires, wants or future intentions. I understand that all questions on a polygraph exam will be in a yes or no only format. I understand that all questions on the EyeDetect will be in a true or false only format. I understand that Polygraph exams and EyeDetect exams are not 100% accurate and have a variable margin of error. I understand that the Subject takes the examination at his/her own risk and of his/her own free will. I understand, consent and agree to hold harmless and release all liability of any kind against Validate, LLC or its members.

Section E: Statement Collection
SECTION E: STATEMENT COLLECTION
In the space below, tell us the entire story, from beginning to end, without omitting or withholding any details, as to what happen that is causing you to take a lie detector test. Do not insert your questions into your statement. You will have the opportunity to provide questions in the next section of this form. There is no text limit. Type as much information as needed to tell the complete story. This statement serves as your voice and point of view so ensure you provide as much detail as possible. *
Do not include questions in your statement. You will have the opportunity to provide questions later in this form.

Section F: Question Submission
SECTION F: POLYGRAPH QUESTION SUBMISSION
QUESTION 1: What is the ONE most important question you want ANSWERED more than anything else from the entire exam process? *
Only ONE question may be provided. This ONE question should be your highest priority question for the entire examination process.
QUESTION 2: What is the SECOND most important question you hope to have ANSWERED from the entire Polygraph? (Not applicable for EyeDetect)
Only ONE question may be provided. This ONE question should be your second priority question for the entire examination process.
REMINDER: Lie Detector Tests CAN NOT UNDER ANY CIRCUMSTANCE ask about any of the following:
- State of Mind
- Feelings/Emotions/Affections
- Thoughts
- Fantasies
- Desires
- Wants
- Daydreams
- Future Intentions
- Ideas
- Awareness
- Or any variation/synonym of the above
REMINDER: Questions CAN NOT be:
- Complex, compound or run-on sentances
- Be open ended questions
- Have multiple answers other than "Yes or No"
- Have any answer other than "Yes or No"
- Vague, diluted or non-specefic
REMINDER: All Questions are REQUIRED to Be:
- Specefic and Direct
- "Yes or No" only questions
- Based off facts or actions only
- Reasonable for the Subject to be able to truthfully answer
I confirm that the question(s) I submitted meet the guideline declared above. *

Yes. I confirm the question(s) I submitted meet all the guidelines declared above.

Section G: Evidence Collection
SECTION G: EVIDENCE COLLECTION
Is there any evidence to support the accusations being made against the Subject? If yes, please describe the evidence in detail in the box below. You can also upload copies of any files, photos or other digital evidence you may have below.
Upload a copy of any files, photos or other digital evidence you want to share:

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Upload a copy of any files, photos or other digital evidence you want to share:

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Upload a copy of any files, photos or other digital evidence you want to share:

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Section H: 15-Point Credibility Assessment
SECTION H: 15-POINT CREDIBILITY ASSESMENT
1. Are you, the Accuser, an honest person?
2. Is the Subject an honest person?
3. How reasonable do you think it is to have the Subject take a lie detector test? *
4. Are you willing to take a lie detector test? If no, explain why not. *
5. What do you think the results of the exam will be and why? *
6. How do you feel about having the Subject take a lie detector test? *
7. Why should the examiner believe you? *
8. Why should the examiner not believe the Subject? *
9. Do you think people that have done what you are accusing the Subject of doing should be given a second chance? *
10. Name three adults that you have a long-term relationship with that you have never lied to? *
11. If the Subject fails the lie detector test, should they be forgiven? *
12. If the Subject passes the lie detector test, what should happen? *
13. Have you lied, omitted, withheld or otherwise not been 100% truthful at any point on this entire form? If yes, please explain in the space below. *
14. Have you ever lied to the Subject? If yes, please explain. *
15. Describe what an abusive relationship is? *

Section I: Policies & Notices:
SECTION I: POLICIES & NOTICES
Due to COVID-19, only the Subject taking the exam is permitted in the building. No other person is permitted in the building, office or exam room on the day of the exam. For this reason, other parties are instructed not to attend. If other parties attend, they will be required to wait out in their vehicles. *

I understand that only the Subject taking the exam is permitted within the building and I will not be attending on the examination date.
Release of Liability Statement: I freely and voluntarily agree to be interviewed and to undergo polygraph examination(s) and/or EyeDetect exam(s) by Validate, LLC and its members. I understand and voluntarily agree that the interview is separate and exclusive from the polygraph examination(s) and/or EyeDetect exam(s) itself. I understand, voluntarily agree and consent that the polygraph examiner or EyeDetect proctor may use the information gathered during my interview(s) in any way. I may consult privately with a lawyer at my own expense or, for minors, with my parent(s),prior to the interview(s) and polygraph examination(s). The interview(s) and/or polygraph examination(s) will be terminated at any time I request. All questions to be asked in the polygraph examination(s) will be discussed with the Subject prior to the actual testing. All questions on the EyeDetect exam will not be discussed prior to testing. I hereby authorize and request that employees of Dawn Nash & Triune Investigative Services disclose to any and all information, conclusions, and opinions arising out of or connected with my interview(s) and polygraph examination(s), even though such information. conclusions, and opinions may be unfavorable or may result in adverse consequences to me. I have been advised and understand that polygraph tests and eyedetect tests are not 100% reliable and are not 100% accurate. I assume all risk and liability taking a polygraph exam or eyedetect exam. I hereby release and forever discharge Validate, LLC, its member, Dawn Nash & Triune Investigative Services and their employees, agents, representatives, partners, officers, directors, and their successors from all liability, and from each and every demand, claim, or cause of action existing, or which may hereafter arise, resulting directly or indirectly from the conduct of my interview(s) and/or polygraph examination(s), eyedetect and/or publication, communication or dissemination of any information, conclusions, and opinions arising out of or connected with my interview(s), eyedtect(s) and/or polygraph examination(s). I have carefully read this entire “Release and Waiver of Liability,” I fully understand this statement. By signing below, I acknowledge that I have reviewed and completed this “Waiver and Release of Liability” personally and with enough time to deliberate upon its contents. My agreement to undergo interview(s), eyedetect exam(s) and/or polygraph examination(s) is given without threats, promises of leniency or immunity, reward or favoritism, duress, pressure or force. I believe my cooperation with Validate, LLC Dawn Nash & Triune Investigative Services is in my own best interest. By clicking the dot next to this statement, signing your signature at the bottom of this form and submitting this form you freely and voluntarily agree to all parts of this statement. *

Yes. I understand, agree and consent to the Release of Liability Statement.

Section J: Sign & Submit
SECTION J: CONFIRM, SIGN AND SUBMIT
I, the Subject, hereby confirm under any applicable laws, that the statements made by me within this form are the truth, the whole truth and nothing but the truth.
Signature *

Clear
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Should be Empty:

ACCUSER/VICTIM'S FORM: Case Information Form