Attachment 3 - Security Clearance Forms.docx

36TH MEDICAL GROUP ANDERSEN AFB GUAM

DHA Background Check/ Security Clearance DHA NIP Memo Position Description PWS or SOW

OF-306

Applicant’s Resume Passport Driver’s License

DD254

IRC Forms Needed

DD-2981 (included with NIP packet)

DA-5018-R

DD-3058

Substance Abuse SUD Release form image4.emf

DD 2981.pdf

PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Controlled by: OUSD(P&R) CUI Category: PRVCY

LDC: FEDCON

POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil

DD FORM 2981, DEC 2021

BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION

(Department of Defense Child Care Services Programs)

OMB No. 0704-0516 OMB approval expires:

20241031

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT

AUTHORITY: 34 U.S.C 20351, Child Care Worker Employee Background Checks Requirements for Background Checks; Public Law 115-91, Section 925, (NDAA for FY2018) Background and Security Investigations for Department of Defense Personnel (10 U.S.C. 1564 note); 5 U.S.C. 9101, Access to Criminal History Records for National Security and Other Purposes; Executive Order 10450 Security Requirements for Government Employees; DoD Instruction 1402.05, Background Checks on Individuals in DoD Child Care Services Programs; DoD Manual 1402.05, Background Checks on Individuals in Department of Defense Child Development and Youth Programs.

PRINCIPAL PURPOSE(S): To collect criminal history information of DoD personnel or contractors seeking to work with children in DoD child care services programs. Information received may be used to assess preliminary interim, on-going, or final suitability/fitness of DoD personnel or contractors working with children in these programs.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, these records may specifically be disclosed outside of DoD pursuant to 552a(b)(3), including as follows: To designated officers and employees of Federal, State, local, territorial, tribal, international, or foreign agencies, or other public authorities, or to other offices or establishments in the executive, legislative, or judicial branches of the Federal Government, in connection with the hiring or retention of an employee, the conduct of a suitability, credentialing, or security investigation, the classifying of jobs, the letting of a contract, or the issuance of a license, grant or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter and the Department deems appropriate; to the appropriate Federal, State, local, territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law.

A complete list of routine uses may be found in the applicable System of Records Notice (SORN), DUSDI-02 DoD, Personnel Vetting Records System, at https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDI-02-DoD.pdf

DISCLOSURE: Voluntary. However, failure to provide all requested information may result in an unfavorable adjudication or determination regarding suitability or fitness to work with children.

1. NAME (Last, First, and Middle Name) (Do not use initials or abridgements.) 2. OTHER NAME(S) USED

3. DATE OF BIRTH (YYYYMMDD) 4. INSTALLATION/PROGRAM NAME 5. DATE OF HIRE (YYYYMMDD)

6. Have you EVER been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category. For any YES answers, complete columns 1-6 and provide a complete summary of the incident on page 2, block 9. Summary should include any disposition or potential mitigating information.

CHILD ABUSE/

NEGLECT: Yes No DRUG OR ALCOHOL: Yes No VIOLENT CRIME/

ASSAULTIVE BEHAVIOR: Yes No

SEX CRIME: Yes No DOMESTIC VIOLENCE: Yes No OTHER: Yes No

(a) Month/ Year(MM/YYYY) (b) Offense (c) Action

Taken

(d) Court or Law Enforcement Agency

(City & Country if outside the United States) (e)

State

(f) Zip

Code

(g) Date of Self- Report(YYYYMMDD)

7. I certify that the information provided above is accurate. I understand that I must immediately report to my employer/supervisor or Child and Youth Program representative if I am apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law referenced in block 6. In addition, I will immediately report when I am aware of a current allegation/investigation of child abuse/neglect or domestic violence, or have otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.

a. SIGNATURE b. DATE (YYYYMMDD)

8. ANNUAL CERTIFICATIONS (Required by Child Development and Youth Program Staff and Volunteers. Certify for the most year recent only. ) In the past year, have you been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.

Failure to disclose accurate information may be grounds for dismissal, termination, or debarment from participating in the program.

a. 2nd YEAR (Yes or No)

(1) SIGNATURE (2) DATE

(YYYYMMDD)

b. 3rd YEAR

c. 4th YEAR

d. 5th YEAR

Failure to provide information may result in an unfavorable adjudication decision.

BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION

(Department of Defense Child Care Services Programs)

9. NOTES (Use this space to enter additional comments.)

10. AUTHORIZATION AND RELEASE CERTIFICATION

I hereby authorize the Department of Defense and other authorized federal agencies to obtain any information required from the Federal government, state agencies, and/or foreign governments, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Counterintelligence and Security Agency (DCSA), the U.S. Office of Personnel Management (OPM), the Department of Homeland Security (DHS), (if applicable), and from the State Criminal History Repository for each state where I have resided. This authorization is valid for one year from the date this form was signed or until termination of my affiliation with the Federal Government, whichever is sooner.

I have been notified of any employer’s or Agency's right to require a criminal history records check as a condition of employment, or affiliation with DoD Child Care Services Programs. I understand that I may request a copy of such records as may be available to me under the law. I understand that I have a right to challenge the accuracy and completeness of any information contained in the criminal history records check report. I also understand that pursuant to the Privacy Act, the information collected will be safeguarded, including for the purpose of conducting the background check.

I release any individual, including records custodians, any component of the United States Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of good-faith compliance, or any good-faith attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

I declare under penalty of perjury that the statements made by me on this form are true, complete and correct. In addition to the annual certification, I understand that it is my responsibility to immediately inform my employer/supervisor or Child and Youth Programs representative if I am apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law with a crime referenced in block 6. (Do not include traffic fines of less than $300.). In addition, I will immediately report when I am aware of a current allegation/investigation of child abuse/neglect or domestic violence, or have otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category. I also understand that if I am a family child care provider that I will make the same report for the same offenses for members in my household.

WARNING: False statements are punishable by law and could result in fines and/or imprisonment for up to five years.

a. SIGNATURE b. DATE SIGNED (YYYYMMDD)

11. PARENT CONSENT FOR MINORS:

If the applicant is a minor, a Parent or Legal Guardian must grant permission below for the background checks. The Parent/Legal Guardian is certifying they understand the purposes of these checks and hereby provide consent for the background checks.

a. SIGNATURE OF PARENT/GUARDIAN (if under age 18) b. DATE SIGNED (YYYYMMDD)

INSTRUCTIONS

This Department of Defense Form is to be completed by prospective or current employees, volunteers, DoD contractors or employees of DoD contractors, Family Child Care (FCC) providers, and adults residing in the FCC home upon application for any position within a Department of Defense Child Care Services Programs. The form will be utilized for initial certification that said individual has not been apprehended, arrested, charged, or convicted by Federal, State, or other Local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), Military law, State law, County law, or Municipal law, Regulation or Ordinance, nor have they been apprehended, arrested, charged or held by Federal, State or Local Authorities for any crime or offense involving any of the following: Crime involving a child, sex crime, drug or alcohol offense, domestic violence, violent crime/assaultive behavior, or other. FCC providers will also report the same offenses for members in their household. Individuals who work and volunteer in DoD Child Development and Youth Programs must update this form on an annual basis.

Completion of this form is voluntary; however, failure to provide requested information may result in an unfavorable adjudication or determination regarding suitability or fitness to work with children in support of DoD child care services programs

1. Provide your last, first, and middle name. Do not use initials or abridgements.

2. Provide any other names used to include maiden name.

3. Provide your date of birth in YYYYMMDD format.

4. Provide the installation and DoD program where you seek employment or to volunteer; if operating or residing in a FCC home, provide the address of the FCC home.

5. Provide the date of hire. To be completed by HR or Security Manager.

6. Place an X in the appropriate box based on whether you EVER been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category. Be sure to disclose any covered charges or incidents, even if they were expunged, and/or even if you would not otherwise need to disclose them on an employment application or forms, as they may be identified in the background check process. You must also disclose all covered incidents, even if you did so on a previous consent and self-disclosure form and/or even if the incident was previously adjudicated.

If you answered “Yes,” explain your answer in the space provided. If additional space is needed, use block 9.

Use column 6.g for subsequent self-reports (as applicable).

7. Sign and Date.

8. On an annual basis, for the most recent year only, select the appropriate answer (yes or no) or write in the appropriate response indicating if you have been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.

9. If needed, use this space for additional comments to explain blocks 6 and/or 8.

10. Sign and date.

Page of

PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Document classification when filled in is CUI

CUI (when filled in)

Document classification when filled in is CUI

Controlled by: OUSD(P&R) CUI Category: PRVCY LDC: FEDCON POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil

DD FORM 2981, DEC 2021

Page of

PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Document classification when filled in is CUI

CUI (when filled in)

Document classification when filled in is CUI

BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION

(Department of Defense Child Care Services Programs)

OMB No. 0704-0516 OMB approval expires: 20241031

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT

AUTHORITY: 34 U.S.C 20351, Child Care Worker Employee Background Checks Requirements for Background Checks; Public Law 115-91, Section 925, (NDAA for FY2018) Background and Security Investigations for Department of Defense Personnel (10 U.S.C. 1564 note); 5 U.S.C. 9101, Access to Criminal History Records for National Security and Other Purposes; Executive Order 10450 Security Requirements for Government Employees; DoD Instruction 1402.05, Background Checks on Individuals in DoD Child Care Services Programs; DoD Manual 1402.05, Background Checks on Individuals in Department of Defense Child Development and Youth Programs.

PRINCIPAL PURPOSE(S): To collect criminal history information of DoD personnel or contractors seeking to work with children in DoD child care services programs. Information received may be used to assess preliminary interim, on-going, or final suitability/fitness of DoD personnel or contractors working with children in these programs.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, these records may specifically be disclosed outside of DoD pursuant to 552a(b)(3), including as follows: To designated officers and employees of Federal, State, local, territorial, tribal, international, or foreign agencies, or other public authorities, or to other offices or establishments in the executive, legislative, or judicial branches of the Federal Government, in connection with the hiring or retention of an employee, the conduct of a suitability, credentialing, or security investigation, the classifying of jobs, the letting of a contract, or the issuance of a license, grant or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter and the Department deems appropriate; to the appropriate Federal, State, local, territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law.

A complete list of routine uses may be found in the applicable System of Records Notice (SORN), DUSDI-02 DoD, Personnel Vetting Records System, at https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDI-02-DoD.pdf

DISCLOSURE: Voluntary. However, failure to provide all requested information may result in an unfavorable adjudication or determination regarding suitability or fitness to work with children.

6. Have you EVER been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category. For any YES answers, complete columns 1-6 and provide a complete summary of the incident on page 2, block 9. Summary should include any disposition or potential mitigating information.

CHILD ABUSE/ NEGLECT:

DRUG OR ALCOHOL:

VIOLENT CRIME/ ASSAULTIVE BEHAVIOR:

SEX CRIME:

DOMESTIC VIOLENCE:

OTHER:

(a) Month/

Year(MM/YYYY)

(b) Offense

(c) Action

Taken

(d) Court or Law Enforcement Agency

(City & Country if outside the United States)

(e) State

(f) Zip Code

(g) Date of Self-Report(YYYYMMDD)

7. I certify that the information provided above is accurate. I understand that I must immediately report to my employer/supervisor or Child and Youth Program representative if I am apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law referenced in block 6. In addition, I will immediately report when I am aware of a current allegation/investigation of child abuse/neglect or domestic violence, or have otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.

8. ANNUAL CERTIFICATIONS (Required by Child Development and Youth Program Staff and Volunteers. Certify for the most year recent only. )In the past year, have you been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.

Failure to disclose accurate information may be grounds for dismissal, termination, or debarment from participating in the program.

Failure to provide information may result in an unfavorable adjudication decision.

BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION

(Department of Defense Child Care Services Programs)

10. AUTHORIZATION AND RELEASE CERTIFICATION

I hereby authorize the Department of Defense and other authorized federal agencies to obtain any information required from the Federal government, state agencies, and/or foreign governments, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Counterintelligence and Security Agency (DCSA), the U.S. Office of Personnel Management (OPM), the Department of Homeland Security (DHS), (if applicable), and from the State Criminal History Repository for each state where I have resided. This authorization is valid for one year from the date this form was signed or until termination of my affiliation with the Federal Government, whichever is sooner.

I have been notified of any employer’s or Agency's right to require a criminal history records check as a condition of employment, or affiliation with DoD Child Care Services Programs. I understand that I may request a copy of such records as may be available to me under the law. I understand that I have a right to challenge the accuracy and completeness of any information contained in the criminal history records check report. I also understand that pursuant to the Privacy Act, the information collected will be safeguarded, including for the purpose of conducting the background check.

I release any individual, including records custodians, any component of the United States Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of good-faith compliance, or any good-faith attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

I declare under penalty of perjury that the statements made by me on this form are true, complete and correct. In addition to the annual certification, I understand that it is my responsibility to immediately inform my employer/supervisor or Child and Youth Programs representative if I am apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law with a crime referenced in block 6. (Do not include traffic fines of less than $300.). In addition, I will immediately report when I am aware of a current allegation/investigation of child abuse/neglect or domestic violence, or have otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category. I also understand that if I am a family child care provider that I will make the same report for the same offenses for members in my household.

WARNING: False statements are punishable by law and could result in fines and/or imprisonment for up to five years.

11. PARENT CONSENT FOR MINORS:

If the applicant is a minor, a Parent or Legal Guardian must grant permission below for the background checks. The Parent/Legal Guardian is certifying they understand the purposes of these checks and hereby provide consent for the background checks.

INSTRUCTIONS

This Department of Defense Form is to be completed by prospective or current employees, volunteers, DoD contractors or employees of DoD contractors, Family Child Care (FCC) providers, and adults residing in the FCC home upon application for any position within a Department of Defense Child Care Services Programs. The form will be utilized for initial certification that said individual has not been apprehended, arrested, charged, or convicted by Federal, State, or other Local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), Military law, State law, County law, or Municipal law, Regulation or Ordinance, nor have they been apprehended, arrested, charged or held by Federal, State or Local Authorities for any crime or offense involving any of the following: Crime involving a child, sex crime, drug or alcohol offense, domestic violence, violent crime/assaultive behavior, or other. FCC providers will also report the same offenses for members in their household. Individuals who work and volunteer in DoD Child Development and Youth Programs must update this form on an annual basis.

Completion of this form is voluntary; however, failure to provide requested information may result in an unfavorable adjudication or determination regarding suitability or fitness to work with children in support of DoD child care services programs

1. Provide your last, first, and middle name. Do not use initials or abridgements.

2. Provide any other names used to include maiden name.

3. Provide your date of birth in YYYYMMDD format.

4. Provide the installation and DoD program where you seek employment or to volunteer; if operating or residing in a FCC home, provide the address of the FCC home.

5. Provide the date of hire. To be completed by HR or Security Manager.

6. Place an X in the appropriate box based on whether you EVER been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law, or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category. Be sure to disclose any covered charges or incidents, even if they were expunged, and/or even if you would not otherwise need to disclose them on an employment application or forms, as they may be identified in the background check process. You must also disclose all covered incidents, even if you did so on a previous consent and self-disclosure form and/or even if the incident was previously adjudicated.

If you answered “Yes,” explain your answer in the space provided. If additional space is needed, use block 9.

Use column 6.g for subsequent self-reports (as applicable).

7. Sign and Date.

8. On an annual basis, for the most recent year only, select the appropriate answer (yes or no) or write in the appropriate response indicating if you have been apprehended, arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law (including the Uniform Code of Military Justice), State law, County law or Municipal law? (Do not include traffic fines of less than $300.) In addition, are you aware of a current allegation/investigation of child abuse/neglect or domestic violence by you, or have you otherwise been involved in any act or received notification from the Family Advocacy Program of an incident that met Department of Defense criteria for child maltreatment or domestic abuse? Mark Yes or No for each category.

9. If needed, use this space for additional comments to explain blocks 6 and/or 8.

10. Sign and date.

9.0.0.2.20120627.2.874785

DD Form 2981, "Basic Criminal History and Statement of Admission (Department of Defense Child and Youth (C&Y) Programs)"

Forms Management Office

DoD Component

CurrentPage:

PageCount:

Name:

Other_Name:

DoB:

Installation_Program_Name:

Hire_Date:

(1) Enter the month and the year of the offense.:

(2) Offense.:

(3) Action taken.:

(4) Court (city and country if outside the U.S.).:

Choose your State Address from the Drop-down list.:

(6) ZIP code.:

(6) ZIP code.:

sigField:

signedDate:

Select "yes" or "no" from drop-down list for second year.:

Select "yes" or "no" from drop-down list for third year.:

sigField2:

(2) DATE (YYYYMMDD):

Select "yes" or "no" from drop-down list for fourth year.:

Select "yes" or "no" from drop-down list for fifth year.:

9. Notes. Use this space to enter additional comments.:

image5.emf

DD 3058 IRC.pdf

Prescribed by: DoDI 1402.05

CONTROLLED When Filled In

DD FORM 3058, OCT 2019

DEPARTMENT OF DEFENSE CONSENT TO CONDUCT INSTALLATION RECORDS CHECK (IRC)

OMB No. 0704-0586 OMB Approval Expires:

20231031

The public reporting burden for this collection of information, OMB Control Number 0704-0586, is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil.

Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT

AUTHORITY: 34 U.S.C. 20351 (Crime Control Act of 1990); DoDI 1402.05, Background Checks on Individuals in DoD Child Care Services Programs; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To require all individuals who provide child care services, as defined by Section 20351 of 34 U.S.C. (Crime Control Act of 1990), to undergo an Installation Records Check (IRC).

ROUTINE USES: The Routine Uses are listed in the applicable system of records notices found at:

Army: A0215-3 SAMR, NAF Personnel Records (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570010/a0215-3-samr/) and A0690-200 DAPE, Department of the Army Civilian Personnel Systems (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570099/a0690-200-dape/) Navy and Marine Corps: NM 01754-3, DON Child and Youth Program, (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570428/nm01754-3/) Air Force: F034 AF SVA C, Child Development/Youth Programs Records (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569755/f034-af-sva-c/) Defense Logistics Agency: S400.20, Day Care Facility Registrant, Applicant and Enrollee Records, (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article- View/Article/570257/s40020/) and National Security Agency: GNSA 19, NSA/CSS Child Development Services, (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570520/ gnsa-19/) This release will be initiated by office or installation staff responsible for the oversight of individuals who provide child care services to children under the age of 18. Once completed, the form will be maintained by the Human Resource (HR) or Security Offices.

DISCLOSURE: Voluntary; however, failure to provide all the requested information could preclude employment or continued service in a child care services program position, and may form the basis for withdrawal of a tentative (conditional) job offer, removal from a position and/or the federal service or prohibition from working with or around children.

SECTION I. SUBJECT'S INFORMATION

1. NAME (Last, First, and Middle Name) (Do not use initials or abridgements) 2. OTHER NAME(S) USED (e.g., maiden name, nickname, birth name)

3. PLACE OF BIRTH (City, State, Country) 4. DATE OF BIRTH (MM/DD/YYYY) 5. SOCIAL SECURITY NUMBER

6. CURRENT ADDRESS (Street, City, State, Zip Code)

SECTION II. AUTHORIZATION AND RELEASE CERTIFICATION (To be signed by Subject or Parent/Legal Guardian)

I hereby authorize the DoD to conduct an IRC, which includes the release of information pertaining to me within military law enforcement records, the Defense Central Index of Investigations (DCII) and information pertaining to Family Advocacy Program (FAP) records (child and/or domestic abuse) maintained in the FAP Central Registry. I also authorize the other Services within DoD to release the same information listed above from their systems of record for the purposes of completing the IRC. I understand that this consent does not expire and may be utilized to conduct periodic re-verification checks. I also understand that except to the extent such action has been taken, I can revoke my consent at any time but this may preclude my continued service in a Child Care Services position. I understand that pursuant to the Privacy Act, the information collected will be confidential and disclosure limited to purposes authorized under the Privacy Act. I understand that I may request a copy of such records as may be available to me under the law, and that I have a right to challenge the accuracy and completeness of any information contained in the results of the background checks. I release any individual, including records custodians, any component of the United States Government, or the individual supplying information, from all liability for damages that may result on account of compliance or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assignees, associates, and personal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

7a. PRINT NAME (Subject or Parent/Legal Guardian) 7b. DATE (MM/DD/YYYY) 7c. SIGNATURE (Subject or Parent/Legal Guardian)

7d. EMAIL ADDRESS 7e. PHONE NUMBER

SECTION III. POSITION AND BACKGROUND CHECK INFORMATION

8a. COMMAND / INSTALLATION / ORGANIZATION 8b. POSITION HIRE / START DATE (estimated) (MM/DD/YYYY)

8c. POSITION CATEGORY

Civilian Employee (APF) Civilian Employee (NAF) Contractor In-Home Care Providers (Respite Care, Foster Care, Family Child Care)

Military Personnel Volunteer In-Home Care Family Members Teen Employee

Junior Reserve Officer (JROTC) Instructor Other https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/140205p.pdf?ver=2019-01-29-103234-310 https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570010/a0215-3-samr/ https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569755/f034-af-sva-c/ https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569755/f034-af-sva-c/ https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570257/s40020/ https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570257/s40020/ https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570520/gnsa-19/ https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570520/gnsa-19/

Prescribed by: DoDI 1402.05

Controlled When Filled In

SECTION IV. INSTALLATION RECORDS CHECK

(To be completed based on service specific procedures)

9. FAMILY ADVOCACY PROGRAM

Type of Check: Initial: Annual: 5 Year Check:

Date initiated: Date Completed:

No record of applicant Record on file

Met criteria incident found: Yes No

Remarks:

I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.

9a. Printed Name of Certifying Official:

9b. Signature: Date:

10. INSTALLATION LAW ENFORCEMENT

No record of applicant: Record on file:

Any derogatory information found: Yes No

I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.

10a. Printed Name and Title:

10b. Signature: Date:

11. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (Optional check)

No record of applicant: Record on file:

Any derogatory information found: Yes No

I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.

11a. Printed Name and Title:

11b. Signature: Date:

https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/140205p.pdf?ver=2019-01-29-103234-310

DRAFT

Prescribed by: DoDI 1402.05

CONTROLLED When Filled In

DD FORM 3058, OCT 2019

Prescribed by: DoDI 1402.05

Controlled When Filled In

DEPARTMENT OF DEFENSE CONSENT TO CONDUCT INSTALLATION RECORDS CHECK (IRC)

OMB No. 0704-0586 OMB Approval Expires: 20231031

The public reporting burden for this collection of information, OMB Control Number 0704-0586, is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT

AUTHORITY: 34 U.S.C. 20351 (Crime Control Act of 1990); DoDI 1402.05, Background Checks on Individuals in DoD Child Care Services Programs; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To require all individuals who provide child care services, as defined by Section 20351 of 34 U.S.C. (Crime Control Act of 1990), to undergo an Installation Records Check (IRC).

ROUTINE USES: The Routine Uses are listed in the applicable system of records notices found at:

Army: A0215-3 SAMR, NAF Personnel Records (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570010/a0215-3-samr/) and A0690-200 DAPE, Department of the Army Civilian Personnel Systems (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570099/a0690-200-dape/)

Navy and Marine Corps: NM 01754-3, DON Child and Youth Program, (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570428/nm01754-3/)

Air Force: F034 AF SVA C, Child Development/Youth Programs Records (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569755/f034-af-sva-c/)

Defense Logistics Agency: S400.20, Day Care Facility Registrant, Applicant and Enrollee Records, (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570257/s40020/) and

National Security Agency: GNSA 19, NSA/CSS Child Development Services, (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570520/gnsa-19/)

This release will be initiated by office or installation staff responsible for the oversight of individuals who provide child care services to children under the age of 18. Once completed, the form will be maintained by the Human Resource (HR) or Security Offices.

DISCLOSURE: Voluntary; however, failure to provide all the requested information could preclude employment or continued service in a child care services program position, and may form the basis for withdrawal of a tentative (conditional) job offer, removal from a position and/or the federal service or prohibition from working with or around children.

SECTION I. SUBJECT'S INFORMATION

SECTION II. AUTHORIZATION AND RELEASE CERTIFICATION (To be signed by Subject or Parent/Legal Guardian)

I hereby authorize the DoD to conduct an IRC, which includes the release of information pertaining to me within military law enforcement records, the Defense Central Index of Investigations (DCII) and information pertaining to Family Advocacy Program (FAP) records (child and/or domestic abuse) maintained in the FAP Central Registry. I also authorize the other Services within DoD to release the same information listed above from their systems of record for the purposes of completing the IRC. I understand that this consent does not expire and may be utilized to conduct periodic re-verification checks. I also understand that except to the extent such action has been taken, I can revoke my consent at any time but this may preclude my continued service in a Child Care Services position. I understand that pursuant to the Privacy Act, the information collected will be confidential and disclosure limited to purposes authorized under the Privacy Act. I understand that I may request a copy of such records as may be available to me under the law, and that I have a right to challenge the accuracy and completeness of any information contained in the results of the background checks. I release any individual, including records custodians, any component of the United States Government, or the individual supplying information, from all liability for damages that may result on account of compliance or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assignees, associates, and personal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

SECTION III. POSITION AND BACKGROUND CHECK INFORMATION

8c. POSITION CATEGORY

SECTION IV. INSTALLATION RECORDS CHECK

(To be completed based on service specific procedures)

9. FAMILY ADVOCACY PROGRAM

Met criteria incident found:

I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.

10. INSTALLATION LAW ENFORCEMENT

Any derogatory information found:

I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.

11. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (Optional check)

Any derogatory information found:

I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.

9.0.0.2.20120627.2.874785

DD Form 3058, "DEPARTMENT OF DEFENSE CONSENT TO CONDUCT INSTALLATION RECORDS CHECK (IRC)"

Click this button to save this form.:

Click this button to print this form.:

Click this Reset button to erase data from all fields.:

1. NAME (Last, First, and Middle Name) (Do not use initials or abridgements):

2. OTHER NAME(S) USED (e.g., maiden name, nickname, birth name):

3. PLACE OF BIRTH (City, State, Country):

4. DATE OF BIRTH (MM/DD/YYYY):

5. SOCIAL SECURITY NUMBER:

6. CURRENT ADDRESS (Street, City, State, Zip Code):

7a. PRINT NAME (Subject or Parent/Legal Guardian):

7b. DATE (MM/DD/YYYY):

7c. SIGNATURE (Subject or Parent/Legal Guardian):

7d. EMAIL ADDRESS:

7e. PHONE NUMBER:

8. COMMAND / INSTALLATION / ORGANIZATION:

8b. POSITION HIRE / START DATE (estimated) (MM/DD/YYYY):

Select Civilian Employee (APF): 0

Select Civilian Employee (NAF): 0

Select Contractor: 0

Select In-Home Care Providers (Respite Care, Foster Care, Family Child Care): 0

Select Military Personnel: 0

Select Volunteer: 0

Select Teen Employee: 0

Select Teen Employee: 0

Select Junior Reserve Officer (JROTC) Instructor: 0

Select Other: 0

Select Initial type of investigation: 0

Select Annual: 0

Select 5 year check: 0

Date initiated::

Date Completed::

Select No record of applicant: 0

Select Record on file: 0

Select Yes: 0

Select No: 0

TextField2:

9a. Printed Name of Certifying Official::

9b. Signature::

Date::

Select Initial type of investigation: 0

Annual:: 0

Annual:: 0

5 Year Check:: 0

5 Year Check:: 0

Date initiated::

Date Completed::

No record of applicant:: 0

No record of applicant:: 0

Record on file:: 0

Record on file:: 0

Yes: 0

Yes: 0

No: 0

No: 0

Remarks::

10a. Printed Name and Title::

10b. Signature::

Date::

Select Initial type of investigation: 0

Date initiated::

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