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

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

CHILD:

Yes

DRUG OR ALCOHOL:

Yes

ASSAULTIVE BEHAVIOR:

SEX CRIME:

Yes

DOMESTIC VIOLENCE:

Yes