DD FORM 3058 Department of Defense Consent to Conduct Installation Records Check (IRC).pdf

DD FORM 3058, OCT 2019

Prescribed by: DoDI 1402.05

Page 1 of 2Controlled by: OUSD(P&R) CUI Category: PRVCY Distribution/Dissemination Control: FEDCON POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil

CUI (when filled in)

CUI (when filled in) (Updated 20260121)

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

OMB No. 0704-0586 OMB Approval Expires:

20261130

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, 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.

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, OR Country, if born outside the US) 4. DATE OF BIRTH (YYYYMMDD) 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 domestic abuse) maintained in the FAP Central Registry to include US State specific Child Abuse/Neglect registries. 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 (YYYYMMDD) 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) (YYYYMMDD)

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 mailto:whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDI-02-DoD.pdf https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDI-02-DoD.pdf

Prescribed by: DoDI 1402.05

CUI (when filled in)

CUI (when filled in)

(Updated 20260121)

DD FORM 3058, OCT 2019

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:(YYYYMMDD) Date Completed: (YYYYMMDD)

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: (YYYYMMDD)

10. INSTALLATION LAW ENFORCEMENT

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

Date initiated: (YYYYMMDD) Date Completed: (YYYYMMDD)

No record of applicant: Record on file:

Any derogatory information 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.

10a. Printed Name and Title:

10b. Signature: Date: (YYYYMMDD)

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

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

Date initiated: (YYYYMMDD) Date Completed: (YYYYMMDD)

No record of applicant: Record on file:

Any derogatory information 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.

11a. Printed Name and Title:

11b. Signature: Date: (YYYYMMDD) https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/140205p.pdf?ver=2019-01-29-103234-310

DRAFT

DD FORM 3058, OCT 2019

Prescribed by: DoDI 1402.05 Controlled by: OUSD(P&R) CUI Category: PRVCY Distribution/Dissemination Control: FEDCON POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI (Updated 20260121)

DD FORM 3058, OCT 2019

Prescribed by: DoDI 1402.05 CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI (Updated 20260121)

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

OMB No. 0704-0586 OMB Approval Expires: 20261130 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, 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.

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 domestic abuse) maintained in the FAP Central Registry to include US State specific Child Abuse/Neglect registries. 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)"

Instructor": 0