5th YEAR Failure to disclose accurate information may be grounds for dismissal termination or disbarment from participating in the program. DD FORM 2981 MAY 2014 Adobe Designer 9. A. SIGNATURE DD FORM 2981 BACK MAY 2014 b. DATE SIGNED INSTRUCTIONS FOR COMPLETING DD FORM 2981 This Department of Defense Form is to be completed by prospective employees and/or volunteers upon application for any position within a Department of Defense Child or Youth Program. The form will be utilized for initial and annual certification that said employee/ volunteer has not 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 nor have they been arrested charged or held by Federal State or Other Law Enforcement Authorities for any crime or offense involving any of the following Crime involving a child sex crime drug or alcohol offense domestic violence violent crime/assaultive behavior or other. OMB No. 0704-0516 OMB approval expires May 31 2017 BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION Department of Defense Child and Youth C Y Programs 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. 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. 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.
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