Attachment 0002 - C-6 IMCOM Worksheet 30A.pdf

FMgr Background Check Request (BCR) Checklist Family Child Care (FCC) Provider

Family Child Care Substitute Provider Respite Care Provider

Emergency Placement Care (EPC) Provider Family/Household Members (FCC and EPC Only)

NOTE: A separate IMCOM 30A MUST be completed for each individual residing in the home. Emergency Placement Care (EPC) requires both parents to be a provider. FCC Substitute and Respite Care Providers are not authorized

Family/Household Members.

Provider’s Name:

Household Member Name:

Garrison Name:

Functional Manager Name:

Initial and Re-Verification Document Requirements (All Categories) ☐ IMCOM Worksheet 30A (1MAY23) ☐ DA Form 5018-R (CSSC template dtd March 2018HQDA ASAP

Child/Youth Svcs Suitability Prog) ☐ IMCOM Form 30 (1MAY22) ☐ DD Form 2981 (DEC21)

Additional Document Requirements Initial- In Home Care Providers (IHCP) and Family/Household Members

FCC/Substitute Respite/EPC Family/Household members (FCC/EPC Only)

☐ Position Description ☐ Position Description ☐ Reference Check(s) – Only submit if reference is derogatory

☐ DA Form 5219 required ☐ Application or Resume ☐ IMCOM Form 30: Only required when request is submitted separately from household (v1 May22)

☐ Reference Check(s) – Only submit if reference is derogatory

☐ Reference Check(s) – Only submit if reference is derogatory

☐ OF-306 (rev. OCT 2019) ☐ OF-306 (rev. OCT 2019)

☐ Residency History Wrksht IMCOM 29 (v1 May23)

☐ Residency History Wrksht IMCOM 29 (v1 May23)

☐ Proof of citizenship ☐ Proof of citizenship IHCP Annual Re-verification & Family/Household 5-Year Re-verification

FCC/Substitute Respite/EPC

☐ Refer to initial and re-verification documents

☐ Refer to initial and re-verification documents

Transfer FCC/Substitute Respite/EPC

☐ IMCOM Worksheet 30A

(1MAY23)

☐ IMCOM Worksheet 30A

(1MAY23)

☐ IMCOM Worksheet 30A

(1MAY23)

☐ IMCOM Form 30 (1MAY22) ☐ IMCOM Form 30 (1MAY22)

☐ Position Description ☐ Position Description

☐ DA Form 5219 required ☐ Application or Resume

☐ HQ IMCOM CYS Transfer Application

*In Home Care Providers have an annual re-verification requirement, therefore their checks should never be more than 12 months old. A re-verification must be submitted within 75 days of the previous re-verification date.

☐ Refer to initial and re-verification documents

Family/Household members (FCC/EPC Only)

Family/Household members (FCC/EPC Only)

IMCOM Worksheet 30A (v1 MAY23) page 2 of 3

FMgr Background Check Request (BCR) Checklist