GSA176

Basic National Agency Check Criminal History

Agency
GSA
Revision
Rev. 11/2015
Fillable fields
75
Pages
2
Official source
GSA form page
Checked
October 20, 2026
Fill GSA176 online
Page 1 of form GSA176

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

GSA Form 176, Basic National Agency Check Criminal History (Child Care Workers), is a General Services Administration form, GSA 176 (REV. 11/2015), with OMB Control Number 3090-0287 and an expiration date of 12/31/2027. GSA hosts it in its forms library, and its page lists the authority The Crime Control Act of 1990, Public Law 101-647.

The form says it is to be used for child care only. Its purpose statement says the Crime Control Act of 1990 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, and that GSA 176 collects information to determine an individual's eligibility for employment to provide child care services in facilities operated by the Federal Government.

The front holds nine instructions, name data in items 1 to 5 and questions 6 to 13 on court-martial, current charges, job history, Federal debt, convictions, military service and police record. The back holds the authorization and release, Privacy Act statements, the burden statement and the signed certification. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of GSA Form 176: Basic National Agency Check Criminal History (Child Care Workers), as printed by GSA

What's on GSA Form 176

Instructions

Nine numbered instructions at the top: ink color, answering every question, initialing changes, 2-letter state abbreviations, area codes, date formats and extra sheets.

Items 1 to 5: name data

Full name, other names used, place of birth, date of birth and Social Security Number. The form says initials and abridgements are not acceptable.

Questions 6 to 10: record and debts

Military court-martial in the past 7 years, current charges, leaving a job under listed conditions in the last 5 years, delinquent Federal debt, and convictions, imprisonment, probation or parole in the last 7 years.

Question 11: military service

Whether you have ever served in the United States Military, with branch, dates and type of discharge for all active duty.

Questions 12 and 13: police record

Arrests, charges or holds in the last 7 years, leaving out traffic fines of less than $150, and whether you have ever been arrested, charged or held for an offense involving a child, sexual offender registry or domestic violence.

Back page: release and certification

Purpose, authorization and release, Privacy Act information and routine uses, the burden statement, final determination, and the signature and date under penalty of perjury.

How to complete GSA Form 176

  1. 1

    Follow GSA's instructions

    The form says to follow the instructions given by the person from GSA who gave you the form, and any other clarifying instructions from that person.

  2. 2

    Answer every question

    The form says all questions on this form must be answered. Where none applies, enter None or N/A, and mark APPROX. or EST. for an estimated date.

  3. 3

    Use the printed formats

    Type or print in black or blue ink, use U.S. Postal Service 2-letter state abbreviations, include area codes, and write dates as mm/dd/yy or mm/yy, for example 5/27/12.

  4. 4

    Explain any Yes answers

    For a Yes on questions 6 to 10, the form asks for details on a separate sheet. Questions 12 and 13 have tables for month and year, offense, action taken and the court or authority.

  5. 5

    Sign the certification

    Review the form, then sign and date the original in black or blue ink. The form says any changes made after signing are initialed and dated.

  6. 6

    Submit the original to GSA

    The form says to submit the original to GSA.

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Submission, time and privacy

Where it goes

The form says to submit the signed original to GSA and to follow the instructions of the person from GSA who gave you the form.

Time to complete

The public reporting burden is estimated to average 30 minutes per response. Comments on the estimate go to Personnel Security Branch (DSP), U.S. General Services Administration, 1800 F Street, NW, Washington, DC 20405.

How the check works

The form says the check is based on fingerprints taken by a law enforcement officer, conducted through the FBI's Identification Division and State criminal history repositories, and initiated through the employing agency's personnel program.

How long the release lasts

The authorization is valid for one year from the date the form was signed or upon termination of affiliation with the Federal Government, whichever is sooner.

Privacy

The form cites Executive Order 10450 and/or Section 231 of the Crime Control Act of 1990 (42 U.S.C. 13041), requests the Social Security number under Executive Order 9397, says disclosure is voluntary, and lists routine uses A to L.

Related forms

Who fills out GSA Form 176?

  • Child care center employees

    Each employee of a child care center located in a Federal building or in Federal leased space, under the Crime Control Act of 1990 as the form describes it.

  • Existing and newly hired staff

    The form says a child care worker employee background check is conducted on all existing and newly hired employees.

  • Workers at contract facilities

    It includes every child care facility operated by the Federal government, or under contract with it, that hires individuals to care for children under the age of eighteen (18).

  • GSA

    A person from GSA gives out the form, the signed original goes to GSA, and the form says the final determination is GSA's responsibility.

The purpose statement on the back says who the background check covers. The form says applicants complete all sections.

Official sources and the blank

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Questions about Form GSA176

Who issues GSA Form 176?

The footer names the General Services Administration and reads GSA 176 (REV. 11/2015). The form carries OMB Control Number 3090-0287, expiration date 12/31/2027. GSA hosts it in its forms library.

Who is GSA Form 176 for?

The form says it is to be used for child care only: employees of child care centers in Federal buildings or Federal leased space, including existing and newly hired employees.

How far back does GSA Form 176 ask?

Questions 6, 10 and 12 cover the past 7 years, question 8 the last 5 years, and questions 11 and 13 ask whether something has ever happened. Question 12 leaves out anything before your 16th birthday.

What if a question does not apply?

The form says to indicate this, for example by entering None or N/A, and to mark APPROX. or EST. for a date you cannot report exactly.

Who makes the final decision?

The form says the final determination for clearance of criminal history is the responsibility of GSA, and that you may be given the opportunity to explain, refute, or clarify any information before a final decision is made.

What does the form say about false statements?

It says false statements are punishable by law and could result in fines and/or imprisonment up to five years. The signature is a declaration under penalty of perjury.

How long does GSA Form 176 take?

The burden statement estimates an average of 30 minutes per response, including the time for reviewing instructions.