ATT_4_-_IRC_Med_Rcds_Release.pdf

REQUEST FOR INSTALLATION RECORDS CHECK (IRC)

Medical Treatment Facility Records

Name of Requesting Agency: ______

POC at Requesting Agency: MSgt Bradley Barkhauer Duty Phone:

_______ _ 1. It is AF policy that Non-Appropriated Fund (NAF) employees and all volunteers working with or near children under 18 years of age must have an IRC. The following individual is being considered for either employment or a volunteer position in a DoD-sanctioned activity:

a. APPLICANT NAME:

b. APPLICANT SSN:

c. APPLICANT DATE OF BIRTH:

d. PROSPECTIVE POSITION:

e. NAME OF MILITARY SPONSOR:

f. SSN OF MILITARY SPONSOR:

g. CURRENT ADDRESS:

2. The Privacy Act protects the information in this letter. AF personnel (military or civilian) must conduct this IRC. Information contained herein should be protected as sensitive medical information.

3. The applicant and the applicant's sponsor acknowledge that both of the social security numbers provided above will be submitted for an AF Central Registry check to verify the applicant has no documented history of perpetrating child maltreatment.

Signature of Applicant (date) Signature of Sponsor (date)

4. For Family Advocacy Program - A Medical Facility Records Check of AHL TA, Mental Health Records and Family Advocacy Program Records, to include an AF Central Registry Check reveals:

__ No pertinent information exists

__ Information exists that requires review

Date Name & Position of FAP Official Signature

FA700018Q0007

Attachment 4

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10 ABW/HC

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1147821758A Typewritten Text