Form DD Form 2981 DD Form 2981 Basic Criminal History and Statement of Admission

CUI (when filled in)
OMB No. 0704-0516
OMB approval expires:
XXXXXXXX

BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION
(Department of Defense Child Care Services 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, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@mail.mil. 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.

PRIVACY ACT STATEMENT
AUTHORITY: 34 U.S.C 20351, Child Care Worker Employee Background Checks Requirements for Background Checks; Public Law 115-91, Section 925, (NDAA for FY2018)
Background and Security Investigations for Department of Defense Personnel (10 U.S.C. 1564 note); 5 U.S.C. 9101, Access to Criminal History Records for National Security and Other
Purposes; Executive Order 10450 Security Requirements for Government Employees; DoD Instruction 1402.05, Background Checks on Individuals in DoD Child Care Services
Programs; DoD Manual 1402.05, Background Checks on Individuals in Department of Defense Child Development and Youth Programs.
PRINCIPAL PURPOSE(S): To collect criminal history information of applicant DoD personnel seeking to work with children in DoD child care services programs. Information received
may be used to assess interim, on-going, or final suitability/fitness of DoD personnel working with children in these programs.
ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, these records may specifically be disclosed outside of DoD
pursuant to 552a(b)(3), including as follows: To designated officers and employees of Federal, State, local, territorial, tribal, international, or foreign agencies, or other public authorities,
or to other offices or establishments in the executive, legislative, or judicial branches of the Federal Government, in connection with the hiring or retention of an employee, the conduct of
a suitability, credentialing, or security investigation, the classifying of jobs, the letting of a contract, or the issuance of a license, grant or other benefit by the requesting agency, to the
extent that the information is relevant and necessary to the requesting agency's decision on the matter and the Department deems appropriate; to the appropriate Federal, State, local,
territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or
potential violation of law.
A complete list of routine uses may be found in the applicable System of Records Notice (SORN), DUSDI-02 DoD, Personnel Vetting Records System, at
https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDI-02-DoD.pdf
DISCLOSURE: Voluntary. However, failure to provide requested information may result in an unfavorable adjudication decision and may affect suitability/fitness for working with
children.

1. NAME (Last, First, and Middle Name) (Do not use initials or abridgements.)

2. OTHER NAME(S) USED

3. DATE OF BIRTH (YYYYMMDD) 4. INSTALLATION/PROGRAM NAME

5. DATE OF HIRE (YYYYMMDD)

6. Have you EVER been apprehended, arrested, charged, convicted, or are aware that you are the subject of a current allegation/investigation of child abuse/
neglect by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law, or met the Family
Advocacy criteria for child maltreatment? (Do not include anything that happened before your 16th birthday. Leave out traffic fines of less than $300.) Mark
Yes or No for each category. For any YES answers, complete columns 1-6 and provide a complete summary of the incident on page 2, block 9. Summary
should include any disposition or potential mitigating information.
CHILD ABUSE/
VIOLENT CRIME/
Yes
No
DRUG OR ALCOHOL:
Yes
No
Yes
No
NEGLECT:
ASSAULTIVE BEHAVIOR:
SEX CRIME:
(1) MONTH/
YEAR

Yes

No

DOMESTIC VIOLENCE:

(2) OFFENSE

Yes

(3) ACTION
TAKEN

No

OTHER:

Yes

No

(4) COURT
(City & Country if outside the United States)

(5)
STATE

(6) ZIP CODE

7. I certify that the information provided above is accurate. I understand that I must immediately report to my employer/supervisor or Child and Youth Program
representative if I am apprehended, arrested, charged, convicted, or become aware that I am the subject of a current allegation/investigation of child abuse/
neglect by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law, or met the Family Advocacy
criteria for child maltreatment referenced in block 6.
a. SIGNATURE

b. DATE (YYYYMMDD)

8. ANNUAL CERTIFICATIONS (Required by Child Development and Youth Program Staff and Volunteers)
In the past year, have you EVER been apprehended, arrested, charged, convicted, or become aware that you are the subject of a current allegation/
investigation of child abuse/neglect by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law,
or met the Family Advocacy criteria for child maltreatment?
Failure to disclose accurate information may be grounds for dismissal, termination, or debarment from participating in the program.
a. 2nd YEAR
(1) SIGNATURE
(2) DATE
b. 3rd YEAR
(1) SIGNATURE
(2) DATE
(Yes or No)

c. 4th YEAR

(YYYYMMDD)

(1) SIGNATURE

(2) DATE

(Yes or No)

(YYYYMMDD)

(Yes or No)

d. 5th YEAR

(YYYYMMDD)

(1) SIGNATURE

(Yes or No)

(2) DATE
(YYYYMMDD)

Failure to provide information may result in an unfavorable adjudication decision.

DD FORM 2981, 20210920 DRAFT

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Controlled by:
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BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION
(Department of Defense Child Care Services Programs)
9. NOTES (Use this space to enter additional comments.)

10. AUTHORIZATION AND RELEASE CERTIFICATION
I hereby authorize the Department of Defense and other authorized federal agencies to obtain any information required from the Federal
government, state agencies, and/or foreign governments, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense
Counterintelligence and Security Agency (DCSA), the U.S. Office of Personnel Management (OPM), the Department of Homeland Security
(DHS), (if applicable), and from the State Criminal History Repository for each state where I have resided. This authorization is valid for one
year from the date this form was signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
I have been notified of any employer’s or Agency's right to require a criminal history records check as a condition of employment, or
affiliation with DoD Child Care Services Programs. I understand that I may request a copy of such records as may be available to me under
the law. I understand that I have a right to challenge the accuracy and completeness of any information contained in the criminal history
records check report. I also understand that pursuant to the Privacy Act, the information collected will be safeguarded, including for the
purpose of conducting the background check.
I release any individual, including records custodians, any component of the United States Government or the individual State Criminal
History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply
with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any
nature. Copies of this authorization that show my signature are as valid as the original release signed by me.
I declare under penalty of perjury that the statements made by me on this form are true, complete and correct. In addition to the annual
certification, I understand that it is my responsibility to immediately inform my employer/supervisor if I am charged with a crime referenced in
block 9 above.
WARNING: False statements are punishable by law and could result in fines and/or imprisonment for up to five years.
a. SIGNATURE

DD FORM 2981, 20210920 DRAFT

b. DATE SIGNED (YYYYMMDD)

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INSTRUCTIONS
This Department of Defense Form is to be completed by prospective or current employees, volunteers, DoD Contractors, Family Child Care
(FCC) providers, and adults residing in the FCC home upon application for any position within a Department of Defense Child Care Services
Programs. The form will be utilized for initial certification that said individual has not been arrested, charged, or convicted by Federal, State,
or other Local 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 Local 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. Individuals who work and
volunteer in DoD Child Development and Youth Programs must update this form on an annual basis.
Completion of this form is voluntary; however, failure to furnish all requested information may affect suitability or fitness determinations for
individuals who may come into regular, recurring contact with children in support of DOD child care services programs
1. Provide your last, first and middle name. Do not use initials or abridgements.
2. Provide any other names used to include maiden name.
3. Provide your date of birth in YYYYMMDD format.
4. Provide the installation and DoD program where you seek employment or to volunteer; if operating a FCC program, or residing in a
FCC home, provide the location of the FCC home.
5. Provide the date of hire. To be completed by HR or Security Manager.
6. Place an X in the appropriate box based on whether you have been apprehended, arrested, charged, convicted, are facing current
pending charges, or are aware that you are the subject of a current allegation/investigation of child abuse/neglect by Federal, State, or
local authorities for an violation of any Federal law, Military law, State law, County or Municipal law, Regulation or Ordinance, or met the
Family Advocacy criteria for child maltreatment. (Do not include anything that happened before your 16th birthday. Leave out traffic fines
of less than $300). Be sure to disclose any covered charges or incidents, even if they were expunged, and/or even if you have been
advised by your attorney that you do not need to disclose them on employment forms, as they may be identified in the background check
process. You must also disclose all covered incidents, even if you did so on a previous consent and self-disclosure form and/or even if the
incident was previously adjudicated.
If you answered “Yes,” explain your answer in the space provided below.
If additional space is needed, use block 9.
7. Sign and Date.
8. On an annual basis select the appropriate answer (yes or no) or write in the appropriate response indicating if you have been
apprehended, arrested, charged, convicted, or are aware that you are the subject of a current allegation/investigation of child abuse/
neglect by Federal, State, or local authorities for any violation of any Federal law, Military law, State law, County or Municipal law, or met
the Family Advocacy criteria for child maltreatment.
9. Use this space for additional comments, if needed, for Blocks 6 and 8.
10. Sign and date.

DD FORM 2981, 20210920 DRAFT

CUI (when filled in)
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