On  at  , I was ordered to give a statement/report by .  I gave my statement/report at his/her order as a condition of employment. I understand that I may face disciplinary action up to and including discharge for disobeying this order, so I have no alternative but to abide by the order. 

It is my belief and understanding that my employer requires my statement/report solely and exclusively for internal purposes and will not release it to any other person or agency. It is my further belief that my statement/report will not and cannot be used against me in any criminal proceedings. 

For any and all other purposes, I hereby reserve my rights as provided by the United States Constitution and any other rights prescribed by law. Further, I rely specifically upon the protection afforded me under Garrity vs. New Jersey, 385 U.S. 439 (1967).  

This invocation of the Garrity right pertains to details within #