DA Form 5220-R "Child Development Services (Cds) Family Child Care (FCC) Provider Background Clearance Request (Lra)"

What Is DA Form 5220-R?

This is a military form that was released by the U.S. Department of the Army (DA) on July 1, 1989. The form, often mistakenly referred to as the DD Form 5220-R, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

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Download DA Form 5220-R "Child Development Services (Cds) Family Child Care (FCC) Provider Background Clearance Request (Lra)"

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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
Title 10, United States Code, Section 3013
AUTHORITY:
To provide background information regarding prospective FCC Providers to CDS personnel for use in the
PRINCIPAL PURPOSE:
certification process.
Information provided may be released IAW the Army's blanket routine uses contained in AR 340-21.
ROUTINE USES:
Disclosure of requested information is voluntary; however, if information is not provided, certification of
DISCLOSURE:
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
9. TO YOUR KNOWLEDGE HAS THERE BEEN ANY CONVICTION OF, ADMISSION TO, OR SUBSTANTIVE EVIDENCE OF
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. 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
ADDRESS
DA FORM, 5220-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
APD LC v2.01ES
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
Title 10, United States Code, Section 3013
AUTHORITY:
To provide background information regarding prospective FCC Providers to CDS personnel for use in the
PRINCIPAL PURPOSE:
certification process.
Information provided may be released IAW the Army's blanket routine uses contained in AR 340-21.
ROUTINE USES:
Disclosure of requested information is voluntary; however, if information is not provided, certification of
DISCLOSURE:
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
9. TO YOUR KNOWLEDGE HAS THERE BEEN ANY CONVICTION OF, ADMISSION TO, OR SUBSTANTIVE EVIDENCE OF
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. 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
ADDRESS
DA FORM, 5220-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
APD LC v2.01ES