TE_3_-_Attch_2._IMCOM_30_WOT_v.1Jun19.pdf

INSTALLATION MANAGEMENT COMMAND (IMCOM)

BACKGROUND CHECK WORK ORDER TICKET

For personnel in child services positions supporting Army programs and activities IAW Army Directive 2014-23 and DODI 1402.05

PRIVACY ACT STATEMENT

AUTHORITY: 42 USC 13041 and 10 USC 3013, Public Law 101-647, Section 231 (Crime Control Act of 1990); DODI 1402.05 (Background Checks on Individualism DoD Child Care Services Programs, 11 Sep 2015, Army Directive 2014-23 (Conduct of Screening and Background Checks For Individuals Who Have Regular Contact With Children in Army Programs), DODI 6060.02 (Child Development Programs (CDPs), 5 Aug 2014), DODI 6060.4 (DoD Youth Programs (YPs), 23 Aug 2004), DoDI 1100.21, Voluntary Services in the Department of Defense, DODI 1400.25, Volume 731 DoD Civilian Personnel Management System: Suitability and Fitness Adjudication For Civilian Employees, 24 Aug 2012, DoD Instruction 1400.25, Subchapter 1403 (DoD Civilian Personnel Manual: Employment), 1 Dec 1996, Incorporating Change 5, 25 Mar 2000, DoD Instruction 1400.25, Volume 1231 DoD /Civilian Personnel Management System: Employment of Foreign Nationals; and E.O. 9397(SSN), as amended, AR 608-18, The Army Family Advocacy.

PURPOSE: To assess the suitability of persons and to determine the loyalty, eligibility, and general trustworthiness of individuals working in child (i.e., children under 18 years of age) services positions.

ROUTINE USE: The DoD "Blanket Routine Users" set forth at the beginning of the Army's compilation of systems of records notices also apply to this system. Uses can be found online at:

http://dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/.

DISCLOSURES: Voluntary; however, failure to furnish all requested information will result in disapproval of the child services application or continued service in child services position.

SECTION I - REQUEST TYPE

Personnel Category: Request Type: ☐ New ☐ Re-Verification ☐ Transfer

Fiduciary Responsibility: ☐ Yes ☐ No Driving Responsibility: ☐ Yes ☐ No Anticipated Start Date:

SECTION II – REQUESTING OFFICE INFORMATION

Garrison: Installation: Directorate/Organization:

Requester Name: Requester Telephone: Requester E-mail:

SECTION III – SUBJECT’S INFORMATION

SSN: Prefix/Rank: Last

Name:

First Name: MI: Maiden Name:

Postfix/Suffix: Birth Date MM/DD/YYYY: Birth Country: Birth State: Birth City:

Citizenship Docs:

(personnel req. INV): Primary E-mail: Secondary E-mail:

Primary Phone: Secondary Phone:

Current Street Address: Current City:

Current State:

Current Zip Code:

Current Country:

Functional Program: Employment Location: Employment Position:

COMPLETE THIS SECTION ONLY IF THIS IS A TRANSFER FILE

Approximate Year Background Check Completed:

Completed by (check one):

☐ CDE ☐ CPAC

Name of Losing Garrison/Installation:

ONLY COMPLETE THIS SECTION FOR VOLUNTEERS, CONTRACTORS (SHORT DURATION) AND OTHER CATEGORIES (FINGERPRINTS) Date fingerprint completed

(MM/DD) :

Date hard copy mailed (when LIVESCAN is down):

Method of delivery: Tracking number:

SECTION IV – FAMILY CHILD CARE/EMERGENCY PLACEMENT CARE

For each person listed below include DA Consent Form. List additional Family Members or residents on a separate page (Category, Name, SSN, DOB and POB)

Category: Name: SSN #: Birth Date: Birth Place:

Category: Name: SSN #: Birth Date: Birth Place:

Category: Name: SSN #: Birth Date: Birth Place:

Category: Name: SSN #: Birth Date: Birth Place:

SECTION V – ONLY COMPLETE I

F CENTRALIZED CONTRACT

Contractor/POC for PSIP purposes: Contractor/POC Phone: E-mail:

Remarks Section (Please note any special requests):

Name and signature of Functional Manager: Date Submitted:

CDE Received (Name and Signature): Date Received:

I MCOM FORM 30, JUN 2019

IMCOM LC v02 ES