Attachment 0002 - C-2 IMCOM Form 30.pdf

INSTALLATION MANAGEMENT COMMAND (IMCOM)

BACKGROUND CHECK REQUEST (BCR) FORM

For personnel in child services positions supporting Army programs and activities IAW Army Directive 2014-23 and DODI 1402.05

SECTION VII- FAMILY CHILD CARE/EMERGENCY PLACEMENT CARE

Category: Name: SSN #: Birth Date: Birth Place:

Category: Name: SSN #: Birth Date: Birth Place:

Category: Name: SSN #: Birth Date: Birth Place:

Category: Name: SSN #: Birth Date: Birth Place:

Remarks Section- Please note any special requests (i.e. Additional "supervisors" for PSIP requests, additional POCs, or information to assist with the processing of the BCR)

Name and signature of Functional Manager: Date Submitted:

CDE Received (Name and Signature): Date Received:

I MCOM FORM 30, 1 MAY 2022 IMCOM LC v04 ES

All household members ages 12 and up must be listed on this form, even if they are not due for a CSBC re-verification. For each person listed below requiring initial or re-verification, refer to IMCOM Worksheet 30A for required documents.

Requester Email:

Garrison:

SECTION II- REQUEST TYPE

or

Personnel Category:

Request Type:

Position Nexus:

Anticipated Start Date:

SSN:

Prefix Last

Name:

First Name: Rank:

Middle Name:

Postfix or

Suffix:

Date of Birth:

Birth Country: Birth City: Birth State:

Maiden Name:

Primary Email:

Secondary Email:

Primary Phone:

Secondary Phone:

Current Street Address:

Current City:

Current State:

Current Zip Code:

Current Country:

Functional Area

Employment Location:

Employment Position:

SECTION I- APPLICANT PROVIDED INFORMATION

Installation: Directorate/Organization:

Requester Name:

Program:

SECTION III- REQUESTING OFFICE INFORMATION (Requesters cannot submit BCR for themselves or supervisory chain of command)

Requester Telephone:

Alternate Name: Alternate Telephone: Alternate Email:

SECTION IV- TRANSFER SECTION (must be completed when transfer is selected) Approximate Year Background Check Completed:

Completed by:

Name of Losing Garrison/Installation:

POC

Email:

SECTION V- VOLUNTEERS, CONTRACTORS (SHORT DURATION) AND OTHER CATEGORIES (FINGERPRINTS) Date fingerprint completed :

Date hard copy mailed (when LIVESCAN is down): Method of delivery: Tracking number:

SECTION VI- CENTRALIZED CONTRACT (only required for Contract Companies that submit fingerprints) Date fingerprint completed : Date hard copy mailed: Method of delivery: Tracking number:

Special Focus

PRIVACY ACT STATEMENT

AUTHORITY: 34 USC 20351 and 10 USC 3013, Public Law 101-647, Section 231 (Crime Control Act of 1990); DODI 1402.05, Background Checks on Individualism DoD Child Care Services Programs, 11 Sep 2015, Army Directive 2014-23 (Conduct of Screening and Background Checks For Individuals Who Have Regular Contact With Children in Army Programs), DODI 6060.02 (Child Development Programs (CDPs), 5 Aug 2014), DODI 6060.4 (DoD Youth Programs (YPs), 23 Aug 2004), DoDI 1100.21, Voluntary Services in the Department of Defense, DODI 1400.25, Volume 731 DoD Civilian Personnel Management System:

Suitability and Fitness Adjudication For Civilian Employees, 24 Aug 2012, DoD Instruction 1400.25, Subchapter 1403 (DoD Civilian Personnel Manual: Employment), 1 Dec 1996, Incorporating Change 5, 25 Mar 2000, DoD Instruction 1400.25, Volume 1231 DoD /Civilian Personnel Management System: Employment of Foreign Nationals; and E.O. 9397(SSN), as amended, AR 608-18, The Army Family Advocacy.

PURPOSE: To assess the suitability of persons and to determine the loyalty, eligibility, and general trustworthiness of individuals working in child (i.e., children under 18 years of age) services positions.

ROUTINE USE: The DoD "Blanket Routine Users" set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.

DISCLOSURES: Voluntary; however, failure to furnish all requested information will result in disapproval of the child services application or continued service in child services position.

cynthia.a.gibbens Cross-Out cynthia.a.gibbens Cross-Out