ATT_3_-_Consent_to_Release_Records.pdf

Acknowledgement of Rights and Consent to Release of Records

Authority: 42 U.S.C. 13041 AND 10 U.S.C. 8013

Principle Purpose: To comply with Public Law 101-647, Section 231, and DoDI 1402.5, Criminal History Background Checks on Individuals working with children under the age of 18.

Disclosure: Mandatory. Refusal to sign this form will prevent the individual's performing services with children under the age of 18 within the Base Chapel Program.

Acknowledgement:

1. I have been advised and understand that the United States Air Force has an obligation to require a record check as a condition of my service in a position involving children under the age of 18. I have also been advised that I have a right to obtain a copy of any criminal history report made available to the agency and to challenge the accuracy and completeness of any information included in such a report.

2. I understand the records check may include the following:

a. An Installation Records Check (IRC) at all installations, I have identified as residences during the preceding two years. This records check will include, as a m:in:imum, inquiries of the Security Forces, ADAPT, Mental Health, and Family Advocacy Office and Family Housing;

b. A State Criminal Repository (SCHR) Check in the state where I currently reside and in states where I have formally resided;

c. A National Agency Check with Inquiries (NACI), including a Federal Bureau of Investigation fingerprint check.

3. I hereby authorize any Federal, State, or Local agency or office to release any record relating to me, which is necessary to complete the records check described above.

Signature: ---------------- Date:

Typed/Printed Name:

Status (Circle one)

ACTIVE DOTY (AD)

RETIRED/CIVILIAN

ACTIVE DOTY FAMILY MEMBER (ADFM) ·

NO MlLITARY AFFILIATION

This document contains FOR OFFICAL USE ONLY (FOUO) information that must be protected under the Privacy Act of 1974 (AF! 33-332). Do not release outside of DoD channels without the consent of the originators' offices ·, FA700018Q0007

Attachment 3