Get DA 5220-R 1989-2024

ADDITIONAL INFORMATION RELEVANT FOR THE PURPOSES OF THIS BACKGROUND CLEARANCE REQUEST MAY BE PROVIDED ON THE REVERSE SIDE. INFORMATION ABOUT OTHER INDIVIDUALS RESIDING IN THE HOME MAY BE ADDRESSED IN THIS SPACE. TITLE ADDRESS SIGNATURE Person submitting information SUBMIT THIS FORM TO ADDRESS LISTED BELOW DA FORM 5220-R JUL 89 EDITION OF AUG 83 IS OBSOLETE USAPPC V2. U.S. DOD Form dod-da-5220-r CHILD DEVELOPMENT SERVICES CDS FAMILY CHILD CARE FCC PROVIDER BACKGROUND CLEARANCE REQUEST For use of this form see AR 608-10 the proponent agency is DCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY Title 10 United States Code Section 3013 PRINCIPAL PURPOSE To provide background information regarding prospective FCC Providers to CDS personnel for use in the certification process. ROUTINE USES Information provided may be released IAW the Army s blanket routine uses contained in AR 340-21. DISCLOSURE Disclosure of requested information is voluntary however if information is not provided certification of the candidate may be denied* NAME OF APPLICANT Last first MI DATE Applicant has applied for certification as a Family Child Care FCC Home Provider within the quarters-based Family Child Care Home System* This office must pursue all means to verify the competency of to provide for the physical social emotional and intellectual needs of young children in a caregiving situation within his/her own home. CHARACTER REFERENCE INFORMATION Check One TO YOUR KNOWLEDGE DOES THIS INDIVIDUAL YES NO N/A 1. RELATE TO CHILDREN AND ADULTS IN A SENSITIVE AND POSITIVE MANNER 2. HAVE THE STAMINA PATIENCE AND CAPABILITY TO CARE FOR CHILDREN FOR SUSTAINED TIME PERIODS 3. SHOW EVIDENCE OF REPUTABLE CHARACTER 4. ACT RESPONSIBILY IN CRISIS SITUATIONS 5. MAINTAIN A SAFE AND SANITARY HOME 6. SPEAK READ AND WRITE ENGLISH TO THE EXTENT HE/SHE CAN EXECUTE HEALTH AND SAFETY DIRECTIONS AND CAN PLAN PROGRAM ACTIVITIES FOR CHILDREN 7. SHOW ANY EVIDENCE OF MENTAL HEALTH PROBLEMS WHICH COULD ADVERSELY AFFECT THE HEALTH OR SAFETY OF CHILDREN IN CARE 8. HAVE ANY ANIMAL s WHICH MIGHT POSE A THREAT TO CHILDREN S WELL BEING AN ACT OF CHILD ABUSE i*e* battering molesting etc* OR NEGLECT USE OF ILLEGAL DRUGS OR ALCOHOL ABUSE BY THIS INDIVIDUAL OR ANY RESIDENT OF THE FCC HOME 10. HOLD ANOTHER JOB EITHER FULL TIME OR PART TIME DURING THE HOURS CHILDREN WOULD BE IN CARE REMARKS EXPLAIN ANY NO ANSWERS TO ITEMS 1 - 6 AND YES ANSWERS TO ITEMS 7 - 10. ROUTINE USES Information provided may be released IAW the Army s blanket routine uses contained in AR 340-21. DISCLOSURE Disclosure of requested information is voluntary however if information is not provided certification of the candidate may be denied* NAME OF APPLICANT Last first MI DATE Applicant has applied for certification as a Family Child Care FCC Home Provider within the quarters-based Family Child Care Home System* This office must pursue all means to verify the competency of to provide for the physical social emotional and intellectual needs of young children in a caregiving situation within his/her own home. .