YOUTH SPORTS VOLUNTEERS BACKGROUND CHECK PACKET PLEASE FILL OUT ALL SECTIONS THAT ARE HIGHLIGHTED. ALL HIGHLIGHTED SECTIONS AND FINGERPRINTS MUST BE COMPLETED BEFORE SUBMISSION. PLEASE CALL YOUR LOCAL SPORTS OFFICE WITH ANY QUESTIONS: AMR: 808-836-1923 SCHOFIELD BARRACKS: 808-655-6465 *YOU WILL BE NOTIFIED WHETHER YOU ARE SUITABLE OR NON- SUITABLE ONCE THE PROCESS IS COMPLETE.
February 2014 Position/Agency Requested: Location: SB AMR CHILD, YOUTH & SCHOOL SERVICES VOLUNTEER/PARTNERSHIP APPLICATION FORM SELF DISCLOSURE STATEMENT DATA REQUIRED BY THE PRIVACY ACT 1974 AUTHORITY: TITLE 10, UNITED STATES CODE, SECTION 3013, AR 608-18, 8-5 PRINCIPLE: ROUTINE: DISCLOSURE: INFORMATION PROVIDED IS USED TO PERFORM BACKGROUND RECORD CHECKS OF PROSPECTIVE CYS SERVICES, VOLUNTEERS, PROVIDERS, CONTRACTORS, AND EDUCATIONAL RESOURCE PARTNERS. IDENTIFYING INFORMATION IS USED TO CONDUCT BACKGROUND RECORD CHECKS OF PROSPECTIVE CYSS VOLUNTEERS, PROVIDERS, AND CONTRACTORS. NO INFORMATION IS DISCLOSED OUTSIDE OF DoD. DISCLOSURE OF ALL INFORMATION IS VOLUNTARY. HOWEVER, MISSING OR INCOMPLETE INFORMATION COULD RESULT IN APPLICANT NOT BEING PLACED. ALL ITEMS BELOW MUST BE COMPLETED NAME: LAST FIRST MI MAIDEN/ALIAS ADDRESS: CITY: STATE: ZIP CODE: PHONE #: DATE OF BIRTH: PLACE OF BIRTH (City & State/Country): SOCIAL SECURITY NUMBER: - - EMAIL: BRANCH OF SERVICE: CIVILIAN: ORGANIZATION/UNIT: RANK: EDUCATIONAL BACKGROUND: REFERENCES (NAME, PHONE #, EMAIL): 1. 2. EXPEREINCE WORKING WITH CHILDREN/YOUTH:
February 2014 Position/Agency Requested: Location: SB AMR COACHING OR VOLUNTEERING EXPERIENCE (YOUTH SPORTS ONLY): HAVE YOU EVER BEEN BONDED? YES NO IF YES, WITH THAT EMPLOYER? HAVE YOU EVER BEEN ARRESTED FOR, OR CONVICTED OF AN OFFENSE INVOLVING A CHILD, YOUTH, OR ADULT, A SEX CRIME, A SUBSTANCE ABUSE FELONY, OR VIOLENT CRIME? YES NO IF YES, PLEASE DESCRIBE: DO YOU HAVE A VALID DRIVERS LICENSE? YES NO IF YES, FROM WHICH STATE? I CERTIFY THAT ALL THE ANSWERS GIVEN BY ME TO ALL THE QUESTIONS ON THIS APPLICATION ARE TO THE BEST OF MY KNOWLEDGE TRUE AND THAT I HAVE NOT WITHELD ANY PERTINENT INFORMATION. I UNDERSTAND THAT ANY OMISSION, MISREPRESENTATION OR FALSE INFORMATION SUBMITTED IN CONNECTION WITH THIS APPLICATION MAY RESULT IN REFUSAL OF A POSITION IN OR SUMMARY DISMISSAL FROM YOUTH SERVICES. I HEREBY AGREE THAT IN THE COURSE OF CONSIDERING MY APPLICATION, YOU MAY MAKE INQUIRY TO ASCERTAIN INFORMATION CONCERNING MY BACKGROUND. I PROVIDE AUTHORIZATION TO CONDUCT A BACKGROUND CHECK IN ACCORDANCE WITH DoDI AND ARMY REGULATIONS TO INCLUDE: LOCAL CIVILIAN LAW ENFORCEMENT (LCLE), PROVOST MARSHALL OFFICE (PMO), ARMY SUBSTANCE ABUSE PROGRAM (ASAP ), MEDICAL TREATMENT FACILITY (MTF ) ARMY CENTRAL REGISTRY (ACR) AND MENTAL HEALTH RECORDS, CRIMINAL INVESTIGATION DIVISION (CID), AND CHILDCARE NATIONAL AGENCY CHECK (CONTRACTORS AND EMPLOYEES ONLY). APPLICANT S SIGNATURE: DATE:
AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION PRIVACY ACT STATEMENT In accordance with the Privacy Act of 1974 (Public Law 93-579), the notice informs you of the purpose of the form and how it will be used. Please read it carefully. AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025.18-R. PRINCIPAL PURPOSE(S): This form is to provide the Military Treatment Facility/Dental Treatment Facility/TRICARE Health Plan with a means to request the use and/or disclosure of an individual's protected health information. ROUTINE USE(S): To any third party or the individual upon authorization for the disclosure from the individual for: personal use; insurance; continued medical care; school; legal; retirement/separation; or other reasons. DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. In addition, any use as an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or disclose psychotherapy notes. SECTION I - PATIENT DATA 1. NAME (Last, First, Middle Initial) 2. DATE OF BIRTH (YYYYMMDD) 3. SOCIAL SECURITY NUMBER 4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD) ANY 5. TYPE OF TREATMENT (X one) OUTPATIENT INPATIENT XX BOTH SECTION II - DISCLOSURE 6. I AUTHORIZE The Military Health System (MHS) TO RELEASE MY PATIENT INFORMATION TO: (Name of Facility/TRICARE Health Plan) a. NAME OF PHYSICIAN, FACILITY, OR TRICARE HEALTH PLAN b. ADDRESS (Street, City, State and ZIP Code) Installation PRB and Agency POC/Child Youth & School (CYS) SPONSOR SSN (all, past 5 Years): Servcies, and Chapel Volunteers/Tiffany Miyashiro/CYS ServicesFTS INSTALLATION: Schofield Barracks c. TELEPHONE (Include Area Code) 808-656-0093 d. FAX (Include Area Code) 808-656-0039 7. REASON FOR REQUEST/USE OF MEDICAL INFORMATION (X as applicable) PERSONAL USE CONTINUED MEDICAL CARE SCHOOL XX OTHER (Specify) Employment, FCC or Volunteer INSURANCE RETIREMENT/SEPARATION LEGAL Screening 8. INFORMATION TO BE RELEASED Mental health information necessary to determine if I have a condition that could impair my judgment, reliability, or fitness for a position requiring routine interaction with children including, if applicable, the nature of the condition, prognosis and dates of treatment. 9. AUTHORIZATION START DATE (YYYYMMDD) 10. AUTHORIZATION EXPIRATION Same as Block 13 XX DATE: Block 13 + 90days ACTION COMPLETED SECTION III - RELEASE AUTHORIZATION I understand that: a. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the facility where my medical records are kept or to the TMA Privacy Officer if this is an authorization for information possessed by the TRICARE Health Plan rather than an MTF or DTF. I am aware that if I later revoke this authorization, the person(s) I herein name will have used and/or disclosed my protected information on the basis of this authorization. b. If I authorize my protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected. c. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance with the requirements of the federal privacy protection regulations found in the Privacy Act and 45 CFR s164.524. d. The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this authorization. I request and authorize the named provider/treatment facility/tricare Health Plan to release the information described above to the named individual/organization indicated. 11. SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE 12. RELATIONSHIP TO PATIENT (If applicable) 13. DATE (YYYYMMDD) SECTION IV - FOR STAFF USE ONLY (To be completed only upon receipt of written revocation) 14. X IF APPLICABLE: 15. REVOCATION COMPLETED BY 16. DATE (YYYYMMDD) AUTHORIZATION REVOKED 17. IMPRINT OF PATIENT IDENTIFICATION PLATE WHEN AVAILABLE SPONSOR NAME: SPONSOR RANK: FMP/SPONSOR SSN: BRANCH OF SERVICE: PHONE NUMBER: DD FORM 2870, DEC 2003 Adobe Professional 8.0
RELEASE/CONSENT STATEMENT PRIVACY ACT STATEMENT AUTHORITY: 42 USC 13041, 10 USC 3013 AND AR 190-45 PRINCIPAL PURPOSE: The provided information will be used to obtain background information through local records checks within the Centralized Operations Police Suite (COPS) and Criminal Justice Information System (CJIS). ROUTINE USES: To initiate background check requirements of the statute. DISCLOSURE: Providing information is voluntary. Failure to provide information may result in disapproval of employment/volunteer status with USAG-HI agencies/units. EMPLOYEE/VOLUNTEER STATEMENT I, (Please print full name), hereby consent to the release of my records and/or information about me contained in any records maintained by the Directorate of Emergency Services (DES) to (requesting Agency/Unit), (installation) for the purpose of potential employment or volunteering for the Unit/Agency. Applicant s Name (Last, First MI.): Applicant s Alias/Maiden Name(s): Social Security Number: Date of Birth: Place of Birth (City, State/Country): Local Address: Home phone number: Business phone number: Date: Applicant s Signature: All request will be scanned in to.pdf format and will be sent to the DES point of contact via Army encrypted email and Public Key Infrastructure (PKI) encryption to ensure security of personally identifiable information (PII). DES FM 3, Feb 14
VOLUNTEER/CONTRACTOR REFERENCE INQUIRY 1. VOLUNTEER/CONTRACTOR NAME: PERSONAL APPRAISAL (Based on your experience with applicant, indicate by check mark in the appropriate column your evaluation of the following factors.) 2. HOW LONG HAVE YOU KNOW APPLICANT AND IN WHAT CAPACITY (IES) (Check applicable block and enter below) CAPACITY SUPERVISOR EMPLOYER FELLOW EMPLOYEE ACQUAINTANCE OTHER (Specify) Insufficient Opportunity to Observe Out-standing APPROXIMATE TIME KNOWN Better than Average Adequate Unsatis-factory 3.a. DEPENDABILITY - Accepts assigned reponsitbity and effectively accomplishes duties in an approved manner within time established. b. COOPERATION - A team worker, maintains good working relationships. c. INITIATIVE AND CREATIVENESS - Ability to think along original lines and to work without detailed instrcutions or supervision d. ABILITY TO ADAPT UNDER PRESSURE - Poise and judgment in meeting adverse or emergency situations. Ability to adjust to changes in working or living environments e. CONSIDERATION FOR OTHERS - Courteous in daily contacts including attitude toward different races, religions, and nationalities. Check applicable block. (If any answer is "YES" to the following questions, give details under "Remarks.") 4. Do you have any reason to question this person's loyalty to the United States? 5. Do you have any knowledge of any behavior, activities, or associations which tend to show that this person is not reliable, honest, trustworthy and of good conduct and character? 6. REMARKS YES NO 7. DATE (YYYYMMDD) 8. YOUR POSITION OR TITLE/PRINT NAME 9. SIGNATURE
VOLUNTEER/CONTRACTOR REFERENCE INQUIRY 1. VOLUNTEER/CONTRACTOR NAME: PERSONAL APPRAISAL (Based on your experience with applicant, indicate by check mark in the appropriate column your evaluation of the following factors.) 2. HOW LONG HAVE YOU KNOW APPLICANT AND IN WHAT CAPACITY (IES) (Check applicable block and enter below) CAPACITY SUPERVISOR EMPLOYER FELLOW EMPLOYEE ACQUAINTANCE OTHER (Specify) Insufficient Opportunity to Observe Out-standing APPROXIMATE TIME KNOWN Better than Average Adequate Unsatis-factory 3.a. DEPENDABILITY - Accepts assigned reponsitbity and effectively accomplishes duties in an approved manner within time established. b. COOPERATION - A team worker, maintains good working relationships. c. INITIATIVE AND CREATIVENESS - Ability to think along original lines and to work without detailed instrcutions or supervision d. ABILITY TO ADAPT UNDER PRESSURE - Poise and judgment in meeting adverse or emergency situations. Ability to adjust to changes in working or living environments e. CONSIDERATION FOR OTHERS - Courteous in daily contacts including attitude toward different races, religions, and nationalities. Check applicable block. (If any answer is "YES" to the following questions, give details under "Remarks.") 4. Do you have any reason to question this person's loyalty to the United States? 5. Do you have any knowledge of any behavior, activities, or associations which tend to show that this person is not reliable, honest, trustworthy and of good conduct and character? 6. REMARKS YES NO 7. DATE (YYYYMMDD) 8. YOUR POSITION OR TITLE/PRINT NAME 9. SIGNATURE
APPROPRIATED FUND ACTIVITIES VOLUNTEER AGREEMENT FOR NONAPPROPRIATED FUND INSTRUMENTALITIES PART I - GENERAL INFORMATION 1. TYPED NAME OF VOLUNTEER (Last, First, Middle Initial) 2. YEAR OF BIRTH X 3. INSTALLATION 4. ORGANIZATION/UNIT WHERE SERVICE OCCURS CYS Services Youth Sports Program 5. PROGRAM WHERE SERVICE OCCURS Schofield Barracks (SB)/Aliamanu Military Reservation (AMR) 8. DESCRIPTION OF VOLUNTEER SERVICES 6. ANTICIPATED DAYS OF WEEK 3 7. ANTICIPATED HOURS 4 9. CERTIFICATION PART II - VOLUNTEER IN APPROPRIATED FUND ACTIVITIES I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved volunteer services, tort claims, the Privacy Act, criminal conflicts of interest, and defense of certain suits arising out of legal malpractice. I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be bound by the laws and regulations applicable to voluntary service providers and agree to participate in any training required by the installation or unit in order for me to perform the voluntary services that I am offering. I agree to follow all rules and procedures of the installation or unit that apply to the voluntary services I will be providing. a. SIGNATURE OF VOLUNTEER b. DATE SIGNED (YYYYMMDD) 10.a. TYPED NAME OF ACCEPTING OFFICIAL (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED (YYYYMMDD) 11. CERTIFICATION PART III - VOLUNTEER IN NONAPPROPRIATED FUND INSTRUMENTALITIES I expressly agree that my services are being provided as a volunteer and that I will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries occurring during the performance of approved volunteer services and liability for tort claims as specified in 10 U.S.C. Section 1588(d)(2). I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits for these voluntary services. I agree to be bound by the laws and regulations applicable to voluntary service providers, and agree to participate in any training required by the installation or unit in order for me to perform the voluntary services that I am offering. I agree to follow all rules and procedures of the installation or unit that apply to the voluntary services that I am offering. a. SIGNATURE OF VOLUNTEER b. DATE SIGNED (YYYYMMDD) 12.a. TYPED NAME OF ACCEPTING OFFICIAL (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED (YYYYMMDD) PART IV - TO BE COMPLETED AT END OF VOLUNTEER'S SERVICE BY VOLUNTEER SUPERVISOR 13. AMOUNT OF VOLUNTEER TIME DONATED 14. SIGNATURE 15. TERMINATION DATE a. YEARS (2,087 hours=1 year) b. WEEKS c. DAYS d. HOURS (YYYYMMDD) 16.a. TYPED NAME OF SUPERVISOR (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED (YYYYMMDD) DD FORM 2793, MAY 2009 PREVIOUS EDITION IS OBSOLETE. Adobe Professional 8.0
Statement of Understanding and Acknowledgement for CYS Services Employees, Family Child Care (FCC) /Homes Off Post (HOP) Providers, Contract Employees and Volunteers Standards of Conduct and Accountability in Child, Youth and School (CYS) Services Programs 1. Corporal punishment is not an acceptable form of discipline law AR 608-10. CYS Services employees, Family Child Care (FCC) /Homes Off Post (HOP) providers, contract employees, and volunteers will use appropriate discipline/guidance methods to teach children/youth acceptable social behavior. 2. CYS Services employees and FCC/HOP providers will discipline in a consistent way, based on an understanding of individual needs and behaviors of children at various developmental levels. Simple, understandable rules will be established so that expectations and limitations are clearly defined. Discipline will be constructive in nature, including such methods as: a. Separation of the child from the situation by redirection; b. Praise of appropriate behaviors; c. 'Time Out" which requires separation of the child from all activities to help the child recover self-control. "Time out" is not punishment and will never be used as punishment, nor will separation from the group. "Time out" requires a staff member to stay close to the child and engage in calm conversation until the child has recovered. 3. A child may not be punished for lapses in toilet training or refusing food. 4. A child may not be punished by: a. Spanking, pinching, shaking, or other corporal punishment; b. Isolation for long periods; c. Confinement in closets, boxes, or similar places; d. Binding to restrict the movement of mouth or limbs; e. Humiliation or verbal abuse; f. Deprivation of meals, snacks, outdoor play opportunities, or other program components. Restrictions of the use of specific play materials and equipment, or participation in a specific activity should be appropriate to the developmental age of the Statement of Understanding and Acknowledgement for CYS Services Employees, FCC/HOP Providers, Contract Employees and Volunteers Page 1
child. Restrictions are permissible to ensure the safety of others or as part of the strategy to help the child learn self-control. 5. Boundaries for appropriate and inappropriate touching are established to ensure that CYS Services employees, FCC/HOP providers, contractors and volunteers have a clear understanding of what is acceptable and what is not. Appropriate touching involves: a. Recognition of the importance of physical contact to nurturing guidance; b. Adult respect for personal privacy; c. Personal space of children and youth; d. Responses affecting the safety and well-being of the child, such as hand holding when crossing the street; e. CYS Services employees, FCC/HOP providers, contract employees, and volunteers modeling appropriate touching like hugging and holding hands. 6. Examples of appropriate touching may include: a. Hugs; b. Reassuring touches on the shoulder; c. Touches expressively appropriate to instruction, such as instances where handson guidance is needed. Examples may include swimming instruction, where one might require a steadying hand on the back; voice instruction, where one might require a hand placed about the diaphragm; or gymnastics instruction. where one might require steadying hands on the trunk of the body. d. Diapering and assisting a child in proper toileting procedures may require that staff touch the genital areas of a child. e. If a child's genital area needs to be checked for reasons other than diapering or toileting, such as because of an injury or child's complaint, another staff member will be present as a witness. The.incident must be documented, signed by the staff/adult/witness, and discussed with the child's parents by the Program Manager. f. Hugging, appropriate hand holding, rocking of infants, or assisting in physical activities relating to instruction will occur in normal interactions between staff and children. However, children's preferences for these types of contact will be considered. g. Whenever possible, the child will be asked before touching. For example, ask the child if they would like a hug instead of just hugging him/her. Tell children before handling what you have to do. Some examples include "I'm going to change you Statement of Understanding and Acknowledgement for CYS Services Employees, FCC/HOP Providers, Contract Employees and Volunteers Page2
diaper now," "I'm going to help you get dressed," or "I'm going to move you to a quiet area." 7. Inappropriate touching includes: a. Coercion or other forms of exploitation of children and youth; b. Satisfaction of adult needs at the expense of the child; c. Attempts to change child behavior with physical force; d. Physical contact that is in violation of the law and cultural norms. 8. Examples of inappropriate touching include: a. Corporal punishment; b. Forced good-bye hugs and/or kisses; c. Slapping, striking, pinching, prolonged tickling, fondling, molestation, or any physical contact, within reason, that the child or youth describes as making them feel uncomfortable. 9. All allegations of inappropriate touching will be investigated and may be grounds for immediate closure of the FCC/HOP home or reassignment of a CYS Services employee, contract employee, or volunteer until the investigation is completed. 10. The primary Child and Youth Program Assistant (CYPA) and assisting CYPA(s) will always maintain sight and sound supervision of all CDC children under their care. 11. CDC CYPAs will conduct written name-to-face counts once per hour (every 30 minutes for hourly care) and report any discrepancies to the Assistant Director or Director. 12. All individuals who work with children and youth are mandated reporters. If they witness an event that a reasonable person would consider child abuse or neglect, they are required to report directly to the Reporting Point of Contact and will immediately do so. If an event occurs that a reasonable person would not consider child abuse or neglect, but is still a violation of this guidance, they must immediately verbally report it to their supervisor or other management staff and then follow-up in writing. 13. CDC CYPAs /providers are responsible for maintaining specific accountability for each CDC child in their group. Systems in place will account for children's whereabouts at regular intervals, especially during periods of transition. CYPAs who observe a child slipping away from or leaving his/her primary care group will immediately advise the Statement of Understanding and Acknowledgement for CYS Services Employees, FCC/HOP Providers, Contract Employees and Volunteers Page 3
primary CYPA. CYPAs are responsible for assisting each other as needed. This is not considered abuse/neglect. 14. Staff will ensure that while under LOSS they are in view of another cleared staff member at all times and are wearing the appropriate color coded apparel. When providing LOSS for another employee they will keep that person in sight at all times. My signature acknowledges that I have read, understand, and will comply with the Standard of Conduct SOP on appropriate guidance & discipline, touching, and accountability of children/youth, and my role in prevention and reporting child abuse or neglect in CYS Services programs. Signature Date Print Name Statement of Understanding and Acknowledgement for CYS Services Employees, FCC/HOP Providers, Contract Employees and Volunteers Page4
Fingerprint Request (Schofield Barracks ONLY) CYS Services regular specified volunteer, requires an FBI fingerprint check prior to working with children/youth. Provide the completed check to the CYS Services Program Operations Specialist, Debra Blanchard. *Installation Security Office Hours of Operation: Monday thru Friday, 0900-1200 and 1300-1500 Location: Building 580, Room 130 Kolekole Ave between Schofield Inn and Richardson Pool turn on Fournier Ave. When facing the 25 th Infantry Division Headquarters enter the door on the left (closest to Kolekole Ave). *THIS SHEET NEEDS TO BE STAMPED BY FINGERPRINT OFFICE AND BROUGHT BACK TO YOUTH SPORTS.