Form GSA Form 176 GSA Form 176 Basic National Agency Check Criminal History (Child Care

BASIC NATIONAL AGENCY CHECK CRIMINAL HISTORY

OMB Control Number: 3090-0287
Expiration Date: 10/31/2018

(Child Care Workers)

NOTE: This form is to be used for child care only. Applicants must complete all sections on this form.
Failure to disclose any information may result in an unfavorable adjudication decision.
See Privacy Act and Public Reporting Burden Statements
Instructions to Complete this Form
1. Follow the instructions given to you by the person from GSA who gave you the form and any other clarifying instructions furnished by that person to assist you in completion of the
form.
2. You must sign and date, in black or blue ink, the original and submit the original to GSA.
3. Type or legibly print your answers in black or blue ink (if your form is not legible, it will not be accepted).
4. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot
report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."
5. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, GSA may modify the form consistent with your
intent.
6. You must use U. S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.
7. All telephone numbers must include area codes.
8. All dates provided on this form must be in Month/Day/Year (mm/dd/yy) or Month/Year (mm/yy) format. Use numbers (1-12) to indicate months. For example, May 27, 2012, should
be shown as 5/27/12.
9. If you need additional space to complete the form, please use a separate blank sheet of paper and reference the item number continued.

NAME DATA
(Give your full
name. Initials and
abridgements are
not acceptable)

1. NAME (Last, First and Middle Name)
2. Other name(s) Used

3. Place of Birth (City/State, Country)

5. Social Security Number

4. Date of Birth

6. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use a separate sheet of
paper to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

YES

NO

7. Are you currently under charges for any violation of law? If "YES," use a separate sheet of paper to provide the date, explanation of the
violation, place of occurrence, and the name and address of the police department or court involved.

YES

NO

8. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave
any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel
Management or any other Federal agency? If "YES," use a separate sheet of paper to provide the date, an explanation of the problem, reason for
leaving, and the employer's name and address.

YES

NO

9. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other
debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans. If "YES,"
use a separate sheet of paper to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct
the error or repay the debt.

YES

NO

10. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole? (includes felonies, firearms or
explosives violations, misdemeanors, and all other offenses.) If "YES," use a separate sheet of paper to provide the date, explanation of the
violation, place of occurrence, and the name and address of the police department or court involved.

YES

NO

11. MILITARY SERVICE
Have you ever served in the United States Military? If you answered "YES," list the branch, dates, and type of discharge for all
active duty. If your only active duty was training in the Reserves or National Guard, answer "NO."
Branch

YES (if "YES",
provide
information below)

NO

Type of Discharge

From (MM/DD/YYYY) To (MM/DD/YYYY)

12. YOUR POLICE RECORD (Do not include anything that happened before your 16th birthday.)
In the last 7 years, have you been arrested, charged or held by Federal, State or Other Law Enforcement Authorities for any violation of any
Federal law, Military law, State law, County or Municipal law, Regulation or Ordinance? (Leave out traffic fines of less than $150) All other
charges must be included even if they were dismissed. If you answered “YES,” explain your answer in the space provided.
Month/Year

Offense

Action Taken

Law Enforcement Authority or Court (City & Country if outside the United States)

State

YES

NO

ZIP Code

13. Have you ever been arrested, charged, or held by Federal, State, or other Law enforcement authorities for any crime or offense involving: Check Yes or No.
Failure to provide information may result in an unfavorable adjudication decision.
Child

YES

NO

Sexual Offender/Registry

YES

NO

Domestic Violence

YES

NO

If you answered “Yes,” in Question 13 explain your answer in the space provided.
Law Enforcement Authority or Court (City & Country if outside the United States)
Month/Year
Offense
Action Taken

GENERAL SERVICES ADMINISTRATION

State

ZIP Code

GSA 176 (REV. 11/2015)

PURPOSE
The Crime Control Act of 1990 – Public Law 101-647, and associated statutes require each employee of a child care center located in a Federal building or in Federal
leased space to undergo a background check. This includes every child care facility operated by the Federal government, or operated under contract with the Federal
government that hires (or contracts for hire) individuals with the provision to care for children under the age of eighteen (18). In accordance with the Crime Control Act of
1990, GSA 176 is used to collect pertinent information in order to determine an individual’s eligibility for employment to provide child care services in facilities operated by
the Federal Government.
A child care worker employee background check must be conducted on all existing and newly hired employees. The background check is 1) based on fingerprints taken by
a law enforcement officer and on other identifying information, 2) conducted through the FBI's Identification Division and through the State criminal history repositories in
each state in which the potential child care employee has been a resident or has listed in an employment application, and 3) initiated through the personnel program of the
applicable employing agency.
AUTHORIZATION AND RELEASE
I hereby authorize the U.S. General Services Administration and other authorized federal agencies to obtain any information required from the Federal government and/or
state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Security Service (DSS), the U.S. Office of Personnel Management (OPM),
the Department of Homeland Security (DHS), (if applicable), and from the State Criminal History Repository for each state where I have resided and worked. This
authorization is valid for one year from the date this form was signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
I have been notified of any employer’s right to require a criminal history records check as a condition of employment. I understand that I may request a copy of such records
as may be available to me under the law. I understand that I have a right to challenge the accuracy and competencies of any information contained in the report. I also
understand that pursuant to the Privacy Act, the information collected will be confidential, and disclosure limited to purposes authorized under the Privacy Act - mainly to
conduct the background check.
I release any individual, including records custodians, any component of the United States Government or the individual State Criminal History Repository 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, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original
release signed by me.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
Privacy Act of 1974 compliance information. Solicitation of information contained herein is authorized by Executive Order 10450 and/or Section 231 of the Crime Control
Act of 1990 (42 U.S.C. 13041), and may be used as a basis for suitability determinations.
Your social security number is being requested pursuant to Executive Order 9397. Disclosure of the information by you is voluntary. Information may be transferred as a
routine use to appropriate federal, state, local, or foreign agencies when relevant to civil, criminal or regulatory investigation, prosecutions, or pursuant to a request by GSA
or such other agency is in connection with the hiring or retention of an employee, the issuance of a license, grant, or other benefit. Information also may be transferred as a
routine use to a duly authorized official engaged in an investigation or settlement of a grievance, complaint, or appeal filed by an employee. Failure to provide information
requested on this form may result in the government’s inability to determine your suitability for the position applied for or occupied, and may affect your prospects for
employment or continued employment under a government contract, or at a federal facility, or with a government license.
GSA describes how your information will be maintained in the Privacy Act system of record notice published in the Federal Register (http://www.gpo.gov/fdsys/pkg/
FR-2008-04-25/pdf/E8-8935.pdf).
PRIVACY ACT ROUTINE USES
A. To GSA Personnel when needed for official business, including the Security Office, HSPD–12 Points of Contacts, and designated analysts and managers for official
business; and PIV card requesting officials to track, verify, and update identity information of GSA personnel; and Regional Credential Officers (RCOs) to issue and track
PIV ID cards;
B. To verify eligibility of an employee or contractor before granting access to specific resources;
C. To disclose information to agency staff and administrative offices who may restructure the data for management purposes;
D. An authoritative source of identities for Active Directory and Google and other GSA systems;
E. In any legal proceeding, where pertinent, to which GSA is a party before a court or administrative body;
F. To authorized officials engaged in investigating or settling a grievance, complaint, or appeal filed by an individual who is the subject of the record.
G. To a Federal, state, local, foreign, or tribal agency in connection with the hiring or retention of an employee; the issuance of a security clearance; the reporting of an
investigation; the letting of a contract; or the issuance of a grant, license, or other benefit to the extent that the information is relevant and necessary to a decision;
H. To the Office of Personnel Management (OPM), the Office of Management and Budget (OMB), or the Government Accountability Office (GAO) when the information is
required for program evaluation purposes;
I. To a Member of Congress or staff on behalf of and at the request of the individual who is the subject of the record;
J. To an expert, consultant, or contractor of GSA in the performance of a Federal duty to which the information is relevant;
K. To the National Archives and Records Administration (NARA) for records management purposes;
L. To appropriate agencies, entities, and persons when (1) the Agency suspects or has confirmed that the security or confidentiality of information in the system of records
has been compromised; (2) the Agency has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests,
identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by GSA or another agency or entity) that rely upon
the compromised information; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with GSA’s efforts to
respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.
PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 30 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 this burden estimate or
any other aspects of this collection of information, including suggestions for reducing this burden, to Personnel Security Branch (DSP), U.S. General Services
Administration, 1800 F Street, NW, Washington, DC 20405.
FINAL DETERMINATION
The final determination for clearance of criminal history is the responsibility of the U.S. General Services Administration (GSA). You may be provided the opportunity
personally to explain, refute, or clarify any information before a final decision is made.

AUTHORIZATION AND RELEASE AND CERTFICIATION
FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD
RESULT IN FINES AND/OR IMPRISONMENT UP TO FIVE YEARS
I declare under penalty of perjury that the statements Signature
made by me on this form are true, complete and correct.

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE
YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.
Date

GSA 176 (REV. 11/2015) BACK