CUI (when filled in)

Prescribed by: DoDI 1402.05

DEPARTMENT OF DEFENSE CONSENT TO CONDUCT INSTALLATION RECORDS CHECK (IRC)OMB No. 0704-0586
OMB Approval Expires:20261130

The public reporting burden for this collection of information, OMB Control Number 0704-0586, is estimated to average 10 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 the burden estimate orburden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should beaware 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 STATEMENTAUTHORITY: 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 OtherPurposes; 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 DoD personnel or contractors seeking to work with children in DoD child care services programs. Information
received may be used to assess preliminary interim, on-going, or final suitability/fitness of DoD personnel or contractors 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 conductof 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 theextent 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 orpotential 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 all requested information may result in an unfavorable adjudication or determination regarding suitability or fitness to work withchildren.

SECTION I. SUBJECT'S INFORMATION1. NAME (Last, First, and Middle Name) (Do not use initials or abridgements)

3. PLACE OF BIRTH (City, State, OR Country, if born outside the US)

2. OTHER NAME(S) USED (e.g., maiden name, nickname, birth name)

4. DATE OF BIRTH (YYYYMMDD)

5. SOCIAL SECURITY NUMBER

6. CURRENT ADDRESS (Street, City, State, Zip Code)SECTION II. AUTHORIZATION AND RELEASE CERTIFICATION (To be signed by Subject or Parent/Legal Guardian)
I hereby authorize the DoD to conduct an IRC, which includes the release of information pertaining to me within military law enforcement records, the Defense
Central Index of Investigations (DCII) and information pertaining to Family Advocacy Program (FAP) records (child and domestic abuse) maintained in the FAPCentral Registry to include US State specific Child Abuse/Neglect registries. I also authorize the other Services within DoD to release the same information listed
above from their systems of record for the purposes of completing the IRC. I understand that this consent does not expire and may be utilized to conduct periodic
re-verification checks. I also understand that except to the extent such action has been taken, I can revoke my consent at any time but this may preclude mycontinued service in a Child Care Services position. I understand that pursuant to the Privacy Act, the information collected will be confidential and disclosure
limited to purposes authorized under the Privacy Act. I understand that I may request a copy of such records as may be available to me under the law, and that I
have a right to challenge the accuracy and completeness of any information contained in the results of the background checks. I release any individual, including
records custodians, any component of the United States Government, or the individual 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, assignees, associates, andpersonal representatives of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

7a. PRINT NAME (Subject or Parent/Legal Guardian)

7b. DATE (YYYYMMDD)

7d. EMAIL ADDRESS

7c. SIGNATURE (Subject or Parent/Legal Guardian)

7e. PHONE NUMBERSECTION III. POSITION AND BACKGROUND CHECK INFORMATION
8a. COMMAND / INSTALLATION / ORGANIZATION

8b. POSITION HIRE / START DATE (estimated) (YYYYMMDD)

8c. POSITION CATEGORY
In-Home Care Providers(Respite Care, Foster Care, Family Child Care)

Civilian Employee (APF)

Civilian Employee (NAF)

Contractor

Military Personnel

Volunteer

In-Home Care Family Members

Junior Reserve Officer (JROTC)
Instructor

Other

DD FORM 3058, OCT 2019

CUI (when filled in)Teen Employee

Controlled by: OUSD(P&R)
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil

Page 1 of 2

CUI (when filled in)

Prescribed by: DoDI 1402.05

SECTION IV. INSTALLATION RECORDS CHECK (To be completed based on service specific procedures)
9. FAMILY ADVOCACY PROGRAM
Type of Check:

Initial:Annual:Date initiated:(YYYYMMDD)

5 Year Check:

Date Completed: (YYYYMMDD)

No record of applicant

Record on file

Met criteria incident found:

Yes

NoRemarks:
I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.
9a. Printed Name of Certifying Official:

9b. Signature:Date: (YYYYMMDD)

10. INSTALLATION LAW ENFORCEMENT
Type of Check:

Initial:Annual:Date initiated: (YYYYMMDD)

No record of applicant:5 Year Check:

Date Completed: (YYYYMMDD)

Record on file:Any derogatory information found:

Yes

NoRemarks:
I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.
10a. Printed Name and Title:

10b. Signature:Date: (YYYYMMDD)

11. DEFENSE CENTRAL INDEX OF INVESTIGATIONS (DCII) (Optional check)
Type of Check:

Initial:Annual:Date initiated: (YYYYMMDD)

No record of applicant:Any derogatory information found:

5 Year Check:

Date Completed: (YYYYMMDD)

Record on file:

Yes

NoRemarks:
I CERTIFY a records check required by DoDI 1402.05 has been completed and no information exists, unless shown above, that precludes working with children.
11a. Printed Name and Title:

11b. Signature:

DD FORM 3058, OCT 2019

Date: (YYYYMMDD)CUI (when filled in)Page 2 of 2