BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION
(Department of Defense Child and Youth (C&Y) Programs)
OMB No. 0704-0516
OMB approval expires
May 31, 2017
1. NAME (Last, First, and Middle Name) (Do not use initials or abridgements.) 2. OTHER NAME(S) USED
3. PLACE OF BIRTH (City, State, Country) 4. DATE OF BIRTH (MM/DD/YYYY) 5. GENDER (X one)
Male Female
Yes
If you answered “Yes,” explain your answer in the space provided on the back of this form.
NoYes
NoYes
Yes
NoYes
Yes Yes NoNo
No
No
6. INSTALLATION/PROGRAM NAME
7. DATE OF HIRE (To be completed by CDP staff only)
(6)
ZIP CODE
(5)
STATE
(4) LAW ENFORCEMENT AUTHORITY OR COURT
(City & Country if outside the United States)
(3) ACTION
TAKEN
(2) OFFENSE
(1) MONTH/
YEAR
If you answered “Yes,” explain your answer in the space provided below.
b. Have you ever been arrested, charged or held by Federal, State or Other Law Enforcement Authorities for any crime or offense involving any of the
following: Mark Yes or No for each category. Failure to provide information may result in an unfavorable adjudication decision. All other charges must
be included in the space provided below even if they were dismissed. If you answered “Yes,” explain your answer in the space provided below.
8.a. Have you ever been arrested, charged, or convicted by Federal, State, or other Law enforcement authorities for any violation of any Federal law, Military
law, State law, County or Municipal law, Regulation or Ordinance? (Do not include anything that happened before your 16th birthday. Leave out traffic
fines of less than $300.) (X one)
9. ANNUAL CERTIFICATIONS.
In the past year, I have not been arrested, charged or held by law enforcement in regard to anything mentioned in block 8 above.
DOMESTIC VIOLENCE:SEX CRIME:
NoYes
VIOLENT CRIME/
ASSAULTIVE BEHAVIOR:
NoYes
OTHER:
CHILD: DRUG OR ALCOHOL:
DD FORM 2981, MAY 2014
Adobe Designer 9.0
The public reporting burden for this collection of information 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 this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria,
VA 22350-3100 (0704-0516). 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.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE APPROPRIATE C&Y PROGRAM REPRESENTATIVE.
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 10450 and/or Section 231 of the Crime Control Act of 1990 (42 U.S.C. 13041); DoD Instruction 1402.5, Criminal History
Background Checks on Individuals in Child Care Services; DoD Instruction 6060.2, Child Development Programs.
PRINCIPAL PURPOSE(S): To require each employee, DoD contractor, family child care provider, adult family member of a family child care provider, and
specified volunteers of a DoD C&Y program to undergo a background check and to annually self-report changes to his or her criminal history. This form
covers a five year period at the end of which a new form must be initiated. When completed, records are covered by one of the appropriate SORNs:
Army: http://dpclo.defense.gov/privacy/SORNs/component/army/A0608-10_CFSC.html
Navy: http://dpclo.defense.gov/privacy/SORNs/component/navy/NM01754-3.html
Air Force: http://dpclo.defense.gov/privacy/SORNs/component/airforce/F034_AF_SVA-C.html
ROUTINE USES: This form is to be used for DoD C&Y programs only. This form will be initiated by C&Y program staff and will be maintained in C&Y
program offices.The DoD "Blanket Routine Uses" found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html 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
of working with or around children.
a. INITIAL CERTIFICATION (1) Signature
b. 2nd YEAR (1) Signature
Failure to disclose accurate information may be grounds for dismissal, termination, or disbarment from participating in the program.
(2) Date (YYYYMMDD)
(2) Date
(YYYYMMDD)
(X as above)
NoYes
d. 4th YEAR (1) Signature
(2) Date
(YYYYMMDD)
(X as above)
NoYes
e. 5th YEAR (1) Signature
(2) Date
(YYYYMMDD)
(X as above)
NoYes
c. 3rd YEAR (1) Signature
(2) Date
(YYYYMMDD)
(X as above)
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