Dd Form 2981 - Defense Technical Information Center

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OMB No. 0704-0516
BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION
OMB approval expires
(Department of Defense Child and Youth (C&Y) Programs)
May 31, 2017
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:
Navy:
Air Force:
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 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.
1. NAME
2. OTHER NAME(S) USED
(Last, First, and Middle Name) (Do not use initials or abridgements.)
3. PLACE OF BIRTH
4. DATE OF BIRTH
5. GENDER
(City, State, Country)
(MM/DD/YYYY)
(X one)
Male
Female
7. DATE OF HIRE
6. INSTALLATION/PROGRAM NAME
(To be completed by CDP staff only)
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)
Yes
No
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.
VIOLENT CRIME/
Yes
No
CHILD:
Yes
No
DRUG OR ALCOHOL:
Yes
No
ASSAULTIVE BEHAVIOR:
SEX CRIME:
Yes
No
DOMESTIC VIOLENCE:
Yes
No
OTHER:
Yes
No
(1) MONTH/
(3) ACTION
(4) LAW ENFORCEMENT AUTHORITY OR COURT
(5)
(6)
(2) OFFENSE
YEAR
TAKEN
(City & Country if outside the United States)
STATE
ZIP CODE
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.
Yes
No
If you answered “Yes,” explain your answer in the space provided on the back of this form.
a. INITIAL CERTIFICATION (1) Signature
(2) Date
(YYYYMMDD)
(2) Date
(2) Date
b. 2nd YEAR
(1) Signature
c. 3rd YEAR
(1) Signature
(YYYYMMDD)
(YYYYMMDD)
(X as above)
(X as above)
Yes
No
Yes
No
(2) Date
(2) Date
d. 4th YEAR
(1) Signature
e. 5th YEAR
(1) Signature
(YYYYMMDD)
(YYYYMMDD)
(X as above)
(X as above)
Yes
No
Yes
No
Failure to disclose accurate information may be grounds for dismissal, termination, or disbarment from participating in the program.
DD FORM 2981, MAY 2014
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