Dd Form 2893 – Fill Out and Use This PDF

VICTIM ADVOCATE SAFETY PLAN

PRIVACY ACT STATEMENT

In accordance w it h t he Privacy Act of 1974 (Public Law 93 -579), t his not ice inf orms you of t he purpose of t his f orm and how it w ill be used. Please read it caref ully.

AUTHORITY: 5 U.S.C. 301, " Depart ment al Regulat ions" ; 10 U.S.C. 136, Under Secret ary of Def ense f or Personnel and Readiness; and Sect ion 534 of t he Nat ional Def ense Aut horizat ion Act f or Fiscal Year 1995, Public Law 103 -337.

PRINCIPAL PURPOSE(S): The inf ormat ion on t his f orm w ill be used t o provide vict ims of domest ic violence w it h a plan f or increasing t heir personal saf et y and t o prepare vict ims f or st eps t o t ake if f urt her abuse or violence occurs.

ROUTINE USE(S): None.

DISCLOSURE: Volunt ary. How ever, f ailure t o provide t he inf ormat ion may make it more dif f icult t o develop a comprehensive saf et y plan.

REVIEW DATES (YYYYMMDD)

The f ollow ing represent s my plan f or increasing my saf et y and preparing in advance f or t he possibilit y of f urt her abuse or violence. Alt hough I do not have cont rol over my abuser' s behavior, I do have a choice about how t o respond t o him/her and how t o best get myself t o saf et y.

Some of t he t hings I can do are:

1. INCREASING MY OVERALL SAFETY. I may not alw ays be able t o avoid violent incident s. In order t o increase my saf et y, I may use a variet y of st rat egies.

Ican use some or all of t he f ollow ing st rat egies:

a.If I decide t o leave, I w ill: (I w ill pract ice how t o get out saf ely. What doors, w indow s, st airw ells or f ire escapes w ould I use?)

b.I can keep my personal belongings (purse, car keys, et c.) ready and put t hem

(place) in order t o leave quickly.

c.I can t ell and

about t he violence and request t hey call t he milit ary or civilian police if t hey hear suspicious noises coming f rom my house.

d.I can t each my children how t o use t he t elephone t o cont act t he police and t he f ire depart ment , and how t o report violence or ot her problems.

e. I w ill use		as my code w ord w it h my children or my f riends so t hey can call f or help.

f . If I have t o leave my home, I w ill go:

(I should decide t his even if I don' t t hink t here w ill be a next t ime.) If I cannot go t o t he locat ion above, t hen I can go t o:

or

g. I can also t each some of t hese st rat egies t o some/all of my children.

h. When I expect w e are going t o have an incident , I w ill t ry t o move t o a space t hat is low est risk, such as:

(I w ill t ry t o avoid incident s in t he bat hroom, garage, and kit chen, near w eapons or in rooms w it hout access t o an out side door.)

i.I w ill use my judgment and int uit ion. If t he sit uat ion is very serious, I can give my abuser w hat he/she w ant s t o calm him/her dow n. I have t o prot ect myself unt il I/w e are out of danger.

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2. PROTECTING MYSELF DURING AN INCIDENT OR IF PLANNING TO LEAVE. If I am planning t o leave, I should do so

w it hout t elling my abuser f ace-t o-f ace. If I have t o leave quickly (during an incident ), I WILL JUST LEAVE. I w ill not t alk w it h my abuser about it . If I am going t o leave at anot her t ime, I w ill leave w hen my abuser is not home and communicat e w it h him/her lat er by phone or let t er f rom a saf e place.

3. SAFETY WHEN PREPARING TO LEAVE. I may decide t o leave t he residence I share w it h my abuser. I must have a caref ul plan f or leaving in order t o increase my saf et y. My abuser might st rike out and become more violent if he/she believes t hat I am leaving t he relat ionship.

Ican use some or all of t he f ollow ing saf et y st rat egies: a. I w ill leave money and an ext ra set of keys w it h

so I can leave quickly.

b. I w ill keep copies of import ant document s or keys at :

c. I w ill open a savings account by (dat e)

, t o increase my independence.

I w ill use

as t he mailing address so t hat t he mont hly st at ement is not sent t o my home.

d. Ot her t hings I can do t o increase my independence include:

f . I can keep change f or phone calls on me at all t imes. I underst and t hat if I use my t elephone credit card, t he f ollow ing mont h t he t elephone bill w ill t ell my abuser t hose numbers t hat I called bef ore or af t er I lef t . To keep my t elephone communicat ion conf ident ial, I must eit her use coins or a pre-paid phone card or I might get a f riend t o permit me t o use his/her t elephone credit card f or a limit ed t ime w hen I f irst leave.

g. I w ill check w it h

and

t o see w ho w ould be able t o let me st ay w it h t hem or lend me some money.

h. I can leave ext ra clot hes w it h:

i. I w ill not t ell my abuser f ace-t o-f ace t hat I am leaving, or I w ill leave w it hout t alking w it h my abuser.

j. I w ill sit dow n and review my saf et y plan every

in order t o plan t he saf est w ay t o leave t he residence.

(Domest ic violence advocat e or f riend)

has agreed t o help me review t his plan.

k. I w ill rehearse my escape plan and, as appropriat e, pract ice it w it h my children.

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4. ITEMS TO TAKE WHEN LEAVING. If I decide t o leave my abuser, it is import ant t o t ake cert ain it ems w it h me. I may also w ant t o give an ext ra copy of papers and an ext ra set of clot hing t o a f riend just in case I have t o leave quickly.

It ems on t he f ollow ing list are t he most import ant t o t ake. If t here is t ime, I might t ake ot her it ems or st ore t hem somew here out side my home so I can get t o t hem easily.

These it ems might best be placed in one locat ion, so t hat if w e have t o leave in a hurry, I can grab t hem quickly. When I leave, I should t ake:

Ident if icat ion f or myself	Work permit s
Milit ary ident if icat ion Card	Green card
Children' s birt h cert if icat es	Divorce papers/cust ody papers
My birt h cert if icat e	Medical records
Passport s	Lease/rent al agreement s, mort gage payment book
Social Securit y number f or myself , t he DoD sponsor,	Bank books
and my children	School and vaccinat ion records
Money	Insurance papers
Checkbook, ATM (Aut omat ic Teller Machine) card	Address book
Credit cards	Pict ures
Keys - house/car/of f ice	Jew elry
Driver' s license and regist rat ion	Children' s f avorit e t oys and/or blanket s
Medicat ions	Small saleable it ems (not abuser' s propert y)

5. SAFETY IN MY OWN RESIDENCE. If I no longer reside w it h my abuser or if I have my ow n residence, t here are many t hings t hat I can do t o increase my saf et y in my ow n residence. Depending on my residence, it may not be possible t o do all t he measures t hat are list ed here or t o do t hem all at once, but I w ill t ake all of t hem int o considerat ion t o prot ect my saf et y.

Saf et y measures I can use include:

a.I can change t he locks on my doors and w indow s as soon as possible.

b.I can replace w ooden doors w it h st eel/met al doors.

c. I can inst all securit y syst ems including addit ional locks, w indow bars, poles t o w edge against doors, an elect ronic syst em, et c.

d.I can purchase rope ladders t o be used f or escape f rom second f loor w indow s.

e.I can inst all smoke det ect ors and purchase f ire ext inguishers f or each f loor in my house/apart ment .

f . I can inst all an out side light ing syst em t hat light s up w hen a person is coming close t o my house.

g. I w ill t each my children how t o use t he t elephone t o make a t elephone call t o me and t o:

(f riend/clergyperson/ot her) in t he event t hat my abuser t akes t he children.

h.I w ill t ell people w ho t ake care of my children w hich people have permission t o pick up my children. The people I w ill inf orm about pick-up permission include:

School:

Day care st af f : Babysit t er:

Sunday School/religious school t eacher: Teacher:

Ot hers:

i.I can inf orm t he f ollow ing people t hat my abuser no longer resides w it h me and t hey should call t he milit ary or civilian police if he/she is observed near my residence:

Neighbor

Past or/religious leader: Friend:

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6. SAFETY WITH A PROTECTION ORDER. My abuser should obey prot ect ion orders, but I can never be sure. I recognize t hat I may need t o ask t he milit ary or civilian police, t he court s, and t he milit ary commanding of f icer t o enf orce my

prot ect ion order.

The f ollow ing are some st eps t hat I can t ake t o help t he enf orcement of my prot ect ion order:

a. I w ill keep my prot ect ion order at (locat ion):

b. I w ill alw ays keep a copy of my prot ect ion order w it h me. If I change purses/w allet s, t hat ' s t he f irst t hing t hat should go in.

c. I w ill give a copy of my prot ect ion order t o milit ary and civilian police depart ment s in t he communit y w here I w ork, in t hose communit ies w here I usually visit f amily or f riends, and in t he communit y w here I live.

d.There may be a count y regist ry of prot ect ion orders t hat all police depart ment s can call t o conf irm a prot ect ion order. I w ill check t o make sure t hat my order is in t he regist ry. The t elephone number f or t he count y regist ry of prot ect ion orders is:

e.For f urt her saf et y, if I of t en visit ot her count ies, I might f ile my prot ect ion order w it h t he court in t hose count ies. I w ill

regist er my prot ect ion order in t he f ollow ing count ies:

f . I can call t he domest ic violence program if I am not sure about b., c., or d. above or if I have some problem w it h my prot ect ion order.

g. I w ill inf orm my employer, my clergy person, my closest f riends, and

t hat I have a prot ect ion order in ef f ect .

h.If my abuser dest roys my prot ect ion order I can get anot her copy by going t o locat ed at :

i.If my abuser violat es my prot ect ion order, I can call t he police and report a violat ion, cont act my at t orney, call my advocat e, and/or advise t he court of t he violat ion.

j.	If law enf orcement does not help, I can cont act my advocat e or at t orney and w ill f ile a complaint w it h t he chief of t he law
	enf orcement depart ment .
k.	I can also f ile a privat e civil complaint in t he jurisdict ion in t he U.S. w here t he violat ion occurred. I can charge my abuser
	w it h a violat ion of t he prot ect ion order. (I can also ask if t he jurisdict ion w here t he violat ion occurred permit s t he f iling of
	privat e criminal complaint s.) I can call t he domest ic violence advocat e t o help me w it h t his.

7. SAFETY ON THE JOB AND IN PUBLIC. I must decide if and w hen I w ill t ell ot hers t hat my abuser is abusive and t hat I may be at cont inued risk. Friends, f amily and co-w orkers can all of f er prot ect ion. I should caref ully consider w hich people

t o invit e t o help secure my saf et y.

I might do any or all of t he f ollow ing:

a. I can inf orm my boss, t he securit y supervisor, milit ary commanding of f icer, senior enlist ed advisor, and

				at w ork of my sit uat ion.
b. I can ask			t o help screen my t elephone calls at w ork.

c.When leaving w ork, I can:

d.When driving home, if problems occur, I can:

e.If I use public t ransit , I can:

f . I can use dif f erent grocery st ores and shopping malls t o conduct my business and shop at hours t hat are dif f erent t han t hose w hen I w as residing w it h my abuser.

g. I can use a dif f erent bank and t ake care of my banking at hours dif f erent f rom t hose I used w hen residing w it h my abuser.

h. I can also:

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8. SAFETY AND DRUG OR ALCOHOL USE. Many people use alcohol. Many use mood-alt ering drugs. Some drugs are legal, ot hers are not . The Depart ment of Def ense has a zero-t olerance policy f or act ive dut y members w it h regard t o t he use of illegal drugs, and t here are Federal and St at e criminal law s addressing t he use of illegal subst ances. Theref ore, I should caref ully consider t he pot ent ial cost s t o my f amily and me if someone in my f amily is using illegal drugs. But beyond t his,

t he use of any alcohol or ot her drugs can reduce my aw areness and abilit y t o act quickly t o prot ect myself f rom my abuser. Alcohol or drug use may also af f ect t he w ay my abuser responds t o dif f erent sit uat ions. Theref ore, in t he

cont ext of drug or alcohol use, I need t o make specif ic saf et y plans.

If drug or alcohol use has occurred in my relat ionship w it h my abuser, I can enhance my saf et y by some or all of t he f ollow ing:

a.If I am going t o use alcohol, I can do so in a saf e place and w it h people w ho underst and t he risk of violence and are commit t ed t o my saf et y.

b.I can also:

c.If my abuser is using, I can:

d.I might also:

e.To saf eguard my children, I might :

9. SAFETY AND MY EMOTIONAL HEALTH. The experience of being bat t ered and verbally degraded by abusers is usually

exhaust ing and emot ionally draining. The process of building a new lif e f or myself t akes much courage and incredible energy.

To conserve my emot ional energy and resources and t o avoid hard emot ional t imes, I can do some of t he f ollow ing:

a. If I f eel dow n and ready t o ret urn t o a pot ent ially abusive sit uat ion, I can:

b.When I have t o communicat e w it h my abuser in person or by t elephone, I can:

c.I can t ry t o use " I can ..." st at ement s w it h myself and t o be assert ive w it h ot hers.

d.	I can t ell myself : "					"
	w henever I f eel ot hers are t rying t o cont rol or abuse me.
e.	I can read							t o help me f eel st ronger.
f .	I can call					,
	and					as ot her resources t o be of support t o me.

g.Ot her t hings I can do t o help me f eel st ronger are:

h.I can at t end w orkshops and support groups at t he domest ic violence program or: or

t o gain support and st rengt hen my relat ionships w it h ot her people.

I SHOULD NOT KEEP THIS PLAN WITH ME. I SHOULD DISCUSS WITH MY VICTIM ADVOCATE WHERE AND WITH WHOM THIS PLAN WILL BE KEPT.

I SHOULD DETACH THE PHONE LISTING ON THE LAST PAGE AND KEEP IT WITH ME.

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PHONE LIST

DETACH AND KEEP WITH YOU AT ALL TIMES.

TELEPHONE NUMBERS I NEED TO KNOW:

Nat ional Domest ic Violence Hot line: 1-800-799-SAFE

Police Depart ment - home:

Police Depart ment - school:

Police Depart ment - w ork:

Milit ary Police:

Commanding Of f icer/Senior Enlist ed Advisor:

Family Advocacy Program Of f ice:

Chaplain:

Domest ic Violence Hot line:

Domest ic Violence Program/Advocat e:

Count y Regist ry of Prot ect ive Orders:

Work Number:

Supervisor' s home number:

Clergy Person:

At t orney:

School/Daycare:

Doct or:

Friend:

Family Member:

Milit ary One Source - f rom t he U.S.: 1-800-342-9647; overseas: 484-530-5747

Ot her:

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