Appendix_G_DD2981.pdf

PREVIOUS EDITION IS OBSOLETE. Page 1 of 3DD FORM 2981, OCT 2018

BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION

(Department of Defense Child Care Services Programs)

OMB No. 0704-0516 OMB approval expires:

September 30, 2021

The public reporting burden for this collection of information, OMB Control Number 0704-0516, 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 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: Executive Order 10450 and/or 34 U.S. Code § 20351; DoD Instruction 1402.05, Criminal History Background Checks on Individuals in 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 require individuals who come into regular, reoccurring contact with children under the age of 18 years to self-report any arrests, charges or convictions that would keep the individual from obtaining or maintaining a favorable suitability or fitness determination. Programs impacted are referenced within the 34 U.S. Code § 20351 and include impacted individuals such as employees, DoD contractors, family child care providers, adults residing in a family child care home, volunteers, and others with regular reoccurring contact with children. Individuals who work or volunteer in DoD Child Development and Youth Programs must annually self-report changes to his or her status utilizing this form. All individuals required to complete this form must immediately self-report to their employer/supervisor if they are arrested, charged, convicted, or met criteria for any offense listed on the form. When completed, records are covered by one of the appropriate SORNs:

Army: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570012/a0215-fmwrc.aspx Navy: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570428/nm01754-3.aspx Air Force: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569755/f034-af-sva-c/ ROUTINE USES: This form will be initiated by DoD staff and will be maintained in the initiating DoD offices and/or appropriate Human Resources or Security Offices. Information received as a result of this release may be used to assess interim/on-going or final suitability or fitness for DoD personnel working with children. ONLY DoD Child Development and Youth programs are required to update and sign annually. A copy of the form is maintained in the staff member's personnel file. The DoD “Blanket Routine Uses” found at http:// dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/ may apply to these records.

DISCLOSURE: Voluntary; however, failure to furnish all requested information may result in an unfavorable adjudication decision and may affect suitability/fitness.

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

3. DATE OF BIRTH (MM/DD/YYYY) 4. INSTALLATION/PROGRAM NAME 5. DATE OF HIRE

6. Have you been arrested, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law, or met the Family Advocacy criteria for child maltreatment? (Do not include anything that happened before your 16th birthday. Leave out traffic fines of less than $300.) (X one) Mark Yes or No for each category. If you answered “Yes,” explain your answer in the space provided below or on the back of the form in block 9.

Yes NoYes

Yes Yes NoNo

No

DOMESTIC VIOLENCE:SEX CRIME:

NoYesVIOLENT CRIME/

ASSAULTIVE BEHAVIOR:

CHILD ABUSE/

NEGLECT: DRUG OR ALCOHOL:

(1) MONTH/

YEAR (2) OFFENSE (3) ACTION

TAKEN

(4) COURT

(City & Country if outside the United States) (5)

STATE (6) ZIP CODE

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 arrested, charged, convicted, or met criteria for any offense referenced in block 6.

a. SIGNATURE b. DATE (YYYYMMDD)

8. ANNUAL CERTIFICATIONS (Required by Child Development and Youth Program Staff and Volunteers) In the past year, have you been arrested, apprehended, charged, or convicted by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law or met the Family Advocacy criteria for child maltreatment.

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

a. 2nd YEAR (Yes or No)

(1) SIGNATURE (2) DATE

(YYYYMMDD)

b. 3rd YEAR (Yes or No)

(1) SIGNATURE (2) DATE

(YYYYMMDD)

c. 4th YEAR (Yes or No)

(1) SIGNATURE (2) DATE

(YYYYMMDD)

d. 5th YEAR (Yes or No)

(1) SIGNATURE (2) DATE

(YYYYMMDD)

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

PREVIOUS EDITION IS OBSOLETE. Page 2 of 3DD FORM 2981, OCT 2018

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, and/or state agencies, and/or foreign governments, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Investigation Service (DIS), 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 upon 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 competencies 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 confidential, and disclosure limited to purposes authorized under the Privacy Act - mainly to conduct 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 compliance, or any 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.

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 (YYYMMDD)

PREVIOUS EDITION IS OBSOLETE. Page 3 of 3DD FORM 2981, OCT 2018

INSTRUCTIONS

This Department of Defense Form is to be completed by prospective employees, volunteers, DoD Contractors, FCC providers, and adults residing in the 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 arrested, charged, or convicted by Federal, State, or other Local authorities for any violation of any Federal law, Military law, State law, County or Municipal law, Regulation or Ordinance, nor have they been 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. Employees and volunteers of DoD Child

Development and Youth Programs must update this form on an annual basis.

Completion of this form is voluntary; however, failure to furnish all requested information may result in an unfavorable adjudication decision and may affect suitability of working with or around children.

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 or DoD program where you seek employment or to volunteer; if operating a FCC program, or residing in a

FCC home, provide the location of the FCC home.

5. Provide the date of hire.

6. Place an X in the appropriate box if you have or have not been convicted by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law, Regulation or Ordinance, or met the Family Advocacy criteria for child maltreatment? (Do not include anything that happened before your 16th birthday. Leave out traffic fines of less than $300.)

If you answered “Yes,” explain your answer in the space provided below.

If additional space is needed, use block 9.

7. Sign and Date.

8. On an annual basis, circle the appropriate response indicating if you have been arrested, apprehended, charged, or convicted by Federal, State, or local authorities for any violation of any Federal, Military, State or local Authorities or met the Family Advocacy criteria for child maltreatment. Applies to employees and volunteers of DoD Child Development and Youth Programs.

9. Use this space for additional comments, if needed, for Blocks 6 and 8.

10. Sign and date.