Form DS-4096 Civilian Response Corps Database In-Processing Form

OMB APPROVAL NO. 1405-0168
EXPIRES:XX/XX/XXXX
ESTIMATED BURDEN: 60 minutes*

U. S. Department of State

Office of the Coordinator for Reconstruction and
CIVILIAN RESPONSE CORPS DATABASE IN-PROCESSING FORM
Purpose of this form
As a member of the Civilian Response Corps (CRC), you are committed to deploy overseas to any region of the
world in a variety of permissive, non-permissive, and hardship environments in order to conduct reconstruction and
stabilization operations. The information collected on this form will be used in the process to select you for missions,
track your readiness status for missions, facilitate processing you for deployments, assisting support functions while
you are deployed, and facilitate your demobilization after a mission. The CRC is only open to US citizens.
Instructions to Complete this Form
Complete every block on this form. If you do not know the answer to the requested information, leave the block
empty and inform your Civilian Response Corps in-processing coordinator. When test information is requested, use
capital block letters. When a date is requested, use (mm-dd-yyyy) format. Attach your résumé to this form. Upon
completion, submit this form to CRC Operations.
Acronyms
CAC: Common Access Card
CRC: Civilian Response Corps
DoS: Department of State

Last Name

ICE: Individual Communications Equipment
LSE: Life Support Equipment
NBC: Nuclear, Biological, and Chemical
PPE: Personal Protective Equipment

TCE:Team Communications
Equipment
TSE:Team Support Equipment
TTE: Team Transportation
Equipment

First Name

Middle Initial

Social Security Number

Date of Birth (mm-dd-yyyy)

Citizenship

CRC Database Number

Employment Status
Direct Hire

Grade (Government employees only)

Other
Work Office Title/Position (Government employees only)

CRC Component

Home Agency/ Department and Office (Government employees only)

CRC Position Title

Home Address

Work Phone Number

Home Phone Number

Mobile/Cell Phone Number

Work E-Mail address

DS-4096
XX-XXXX

Personal E-Mail Address

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U. S. Department of State E-Mail Address

Expiration Date (mm-dd-yyyy)

U. S. Department of State Badge
Yes
No

Emergency Contact Name and Relation

Passport Type
Personal
Official

Emergency Contact
Diplomatic
Name

Passport Number

Relation
Address
Expiration Date (mm-dd-yyyy)

Driver's License Number and State
Phone Number
Expiration Date (mm-dd-yyyy)
Height (inches)

Weight (pounds)

Hair Color

Eye Color

Blood Type

Language Skills

Military Service Branch and Dates (mm-dd-yyyy) (Where applicable)

Possess Will

Security Clearance
Secret

Yes

No

Top Secret
Power of Attorney on File

Top Secret/SCI
Date Issued (mm-dd-yyyy)

Payroll Direct Deposit Established
Yes

No

Government Purchase Card
Yes
No
Health Care Proxy
Yes

International Driver's License
Yes

Government Travel Card

No

Number of CRC Deployments

No

Yes

No

CAC
No
Yes
Expiration Date (mm-dd-yyyy)

No

MEDEVAC Insurance
Yes
No
DS-4096
XX-XXXX

Yes

Digital Visa Photo
Yes

(6) Visa Photos
No

Yes

No
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Service Agreement
No
Yes
Date (mm-dd-yyyy)

SF-50
Date (mm-dd-yyyy)

Supplemental Medical Statement
Yes
No

CRC Preliminary Medical Exam
Yes
No

Class 1 Medical Clearance
Yes
No

Dental Records
Yes

Date (mm-dd-yyyy)

Date (mm-dd-yyyy)

Yes

Résumé Attached
Yes
No

No

No

Date (mm-dd-yyyy)

CRC General Inoculation/Immunizations

Backup of Digital Personal Documents
Yes

Backup of Digital Medical Records

No

Yes

Date (mm-dd-yyyy)

LSE Issued

No

Yes

Date (mm-dd-yyyy)

Pants

Shirt

Hat

Helmet

Coat

Date (mm-dd-yyyy)
ICE Issued

Personal Gear and Equipment Sizes
Boots

No

Yes
No
Date (mm-dd-yyyy)
TCE Issued

Gloves

NBC Suit

Yes
No
Date (mm-dd-yyyy)

NBC Mask

PPE Vest

TTE Issued
Yes

No

Date (mm-dd-yyyy)

Remarks:

TSE Issued
Yes

No

Date (mm-dd-yyyy)
PD560 Course
Yes

No

HEFAT (OT610-FACT) Course

Date (mm-dd-yyyy)

No

Date (mm-dd-yyyy)

Date (mm-dd-yyyy)

Yes

PD561 Course
Yes

No

RS500 Course
Yes Yes
Date (mm-dd-yyyy)

PD562 Course
Yes

No

Date (mm-dd-yyyy)

No

PD573 Course
Yes

No

Date (mm-dd-yyyy)
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Country/Regional Experience

Sector Experience/Expertise (Criminal Justice and Policing; Diplomacy and Governance; Economic Recovery;
Essential Service; Planning, Operations and Management)

PRIVACY ACT STATEMENT AND PAPERWORK REDUCTION ACT
AUTHORITIES: The information is sought in pursuant to Public Law 108-447; 22 U.S.C. § 2734 (Reconstruction and Stabilization); 5 U.S.C. § 301 (Management
of the Department State); 22 U.S.C. § 2651a (Management of the Foreign Service); and 22 U.S.C. § 3921 (Administration by the Department of State).

PURPOSE: The information collected and maintained in this form will be used to establish and maintain the Civilian Response Corps, to allow for ease in
identifying the best fit of personnel for specific missions, and, in the case of applicants not immediately selected but still of interest for future selection into the Corps,
to maintain a database of potential candidates for the Corps. The information will also support the Department's responsibility to coordinate U.S. Government
planning and execution of R&S missions, to institutionalize U.S. capacity to help stabilize and reconstruct societies in transition from conflict or civil strife to reach a
sustainable path toward peace, democracy and a market economy.
Respondents' social security numbers will be used for the purpose of security checks and to obtain access to military facilities, including manifesting on military
aircraft. Disclosure of this information, including the social security number is voluntary although necessary to receive benefits, to be deployable, and as a condition
for new or continued employment in the Civilian Response Corps. Failure to provide the information requested on this form may result in delays in considering an
application or the application not receiving full consideration or the applicant not receiving benefits.

ROUTINE USES: The information in this system will be used to help the office carry out its mandate to lead, coordinate and institutionalize
stabilization and reconstruction activities of the United States Government. The information will be used to manage and select individuals who are being
considered, have been hired or agreed to deploy overseas in support of reconstruction and stabilization efforts of the U.S. Government Civilian Response Corps.
The information may be shared with other U.S. Government Agencies and state governments involved in reconstruction and stabilization; NATO or similar
international entities or military installations for coordination or access; or with foreign governments and international organizations where employees are being
considered for detail, assignment or secondment or for clearance before a Federal employee is assigned to that country as well as for the procurement of necessary
services for U.S. personnel assigned overseas. Lastly, some information on employees may be shared, for the benefit of and upon the request by these
employees, with attorneys or union representatives, designated in writing by the employee who is the subject of the information, to represent him/her in complaints,
grievances, or other litigation.

*BURDEN: Public reporting burden for this collection of information is estimated to average 60 minutes per response including time required for searching

existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not
have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.

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