Dd Form 2910 – Fill Out and Use This PDF

VICTIM REPORTING PREFERENCE STATEMENT

(Read Privacy Act Statement before completing this form.)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 113 note, Department of Defense Policy and Procedures on Prevention and Response to Sexual Assaults Involving Members of the Armed Forces; 10 U.S.C. 136; 32 U.S.C.; DoD Directive 6495.01; DoD Instruction 6495.02; 10 U.S.C. 3013; Army Regulation 600-20, Chapter 8; 10 U.S.C. 5013; Secretary of the Navy Instruction 1752.4A; Marine Corps Order 1752.5A; 10 U.S.C. 8013; Air Force Instruction 36-6001; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): Information will be used to document elements of the sexual assault response and/or reporting process and comply with the procedures set up to effectively manage the sexual assault prevention and response program. At the local level, Service SAPR Program Management, Major Command Sexual Assault Response Coordinator(s) (SARCs), Installation and Brigade SARCs use information to ensure that victims are aware of services available and have contact with medical treatment personnel and DoD law enforcement entities. At the DoD level, only de-identified data is used to respond to mandated congressional reporting requirements. The DoD Sexual Assault Prevention and Response Office has access to identified closed case information and de-identified, aggregate open case information for congressional reporting, study, research, and analysis purposes. Collected information is covered by DHRA 06 DoD, Defense Sexual Assault Incident Database (http://dpclo.defense.gov/privacy/SORNs/component/osd/DHRA06DoD.html).

ROUTINE USE(S): The DoD blanket routine uses found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html may apply to this record.

Note: Any release made as a blanket routine use will be consistent with the principal purpose of its original collection.

DISCLOSURE: Voluntary. However, if you decide not to provide certain information, it may impede the ability of the SARC to offer the full range of care and support established by the sexual assault prevention and response program. You will not be denied benefits via the Restricted Reporting option. The Social Security Number (SSN) is one of several unique personal identifiers that may be provided. This form will be stored electronically in the Defense Sexual Assault Incident Database (DSAID) for 50 years for Unrestricted Reports.

a. I, (full name)

(Social Security Number)

,

had the opportunity to talk with a Sexual Assault Prevention and Response Victim Advocate (SAPR VA) or a Sexual Assault Response Coordinator (SARC) before selecting a reporting option.

b. UNRESTRICTED REPORTING - REPORTING A CRIME WHICH IS INVESTIGATED.

INITIALS (1) I understand that law enforcement and my command will be notified that I am a victim of sexual assault. An investigation into the crime will be started by an MCIO. I can receive medical treatment, support services, and counseling. I can also choose to have a sexual assault forensic examination if indicated. I will be provided a DD Form 2701 which contains important information about my rights as a victim from the law enforcement or MCIO. I should retain the DD Form 2701. If reporting a sexual assault that occurred prior to or while not performing active service or inactive training, National Guard and Reserve Component members are eligible to receive SAPR support services from a SARC and a SAPR VA and are eligible to file an Unrestricted Report.

(2) As a service member, I understand that:

(a)(Through a separate form) I may request an Expedited Transfer (temporary or permanent) from my installation or to a different location within my installation. My family will be included.

(b)Depending on the facts of my case, I may request a Military Protective Order (MPO). If a written and/or verbal MPO is issued, my commander will provide me with a copy of the DD Form 2873.

(c)I also have the option of requesting a Civilian Protective Order (CPO) from civilian courts.

(3)My Commanding Officer may take appropriate punishment action if there is evidence I committed misconduct around the time of the sexual assault. However, my Commanding Officer is to take into account the sexual assault investigation and circumstances when considering how to address my misconduct.

(4)If the crime is prosecuted under the UCMJ, any communication with my SARC or SAPR VA are confidential under the "Victim-Victim Advocate Privilege" unless an exception applies.

c. RESTRICTED REPORTING - CONFIDENTIALLY REPORTING A CRIME WHICH IS NOT INVESTIGATED.

(1)I understand that l can confidentially receive medical treatment, advocacy services, and counseling. I can also choose to have a sexual assault forensic examination, if indicated. Law enforcement and my command will NOT be notified. My report will NOT cause an investigation of the crime. No action will be taken against the offender(s) as the result of my report. If reporting a sexual assault that occurred prior to or while not performing active service or inactive training, National Guard and Reserve Component members are eligible to receive SAPR support services from a SARC and a SAPR VA and are eligible to file a Restricted Report.

(2)I understand that there are exceptions to "Restricted Reporting" (see Page 2) and they have been explained to me. If an exception applies, the details of my assault may be revealed.

(3)I understand the evidence collected from my Sexual Assault Forensic Exam (SAFE) will be stored for 5 years from the date I sign this form. I will be contacted in 1 year by my SARC to discuss my options as they relate to this evidence. If the case is handled in civilian court, civilian law enforcement would handle the SAFE kit storage.

(4)All state laws, local laws or international agreements that may limit some or all of DoD's Restricted Reporting protections have been explained

to me. In the (state, city/county of		California	, medical authorities must report the sexual
assault to	law enforcement		.

(5)I understand that the SARC will provide information that does not reveal my identity, nor that of my offender, to the responsible senior commander. This notification takes place within 24 hours of my "Restricted Report". If I am at a deployed location or there are extenuating circumstances, the notification will be made within 48 hours. Commanders require this information for public safety and other responsibilities.

(6)I understand that certain protective actions, such as an MPO and/or a CPO against the offender, or an expedited transfer and my victim's rights, will NOT be available to me if I choose Restricted Reporting.

(7)I understand that speaking to others about my sexual assault may result in the crime being reported to command and law enforcement. This could lead to an investigation. I may keep my report confidential by only talking to those persons covered under the "Restricted Reporting" option (SARC, SAPR VA, or healthcare personnel). Communications with Chaplains and Legal Assistance Attorneys are also privileged and may not be disclosed without my consent.

(8)I understand that I may change my mind and report this offense at a later time as an "Unrestricted Report", and law enforcement and my command will be notified. However, delays in changing the report from restricted to unrestricted may affect the amount of evidence gathered by an investigation and may impact the ability to hold offender(s) appropriately accountable.

DD FORM 2910, MAY 2013

PREVIOUS EDITION IS OBSOLETE.

Adobe Designer 9.0

1.c. RESTRICTED REPORTING (Continued)

d.I also understand that:

(1)If I do not choose a reporting option right now or if I refuse to sign this form, the SARC or SAPR VA has no obligation to inform investigators or commanders about my sexual assault. The SARC or SAPR VA may only disclose information about our conversation according to the exceptions to the Victim-Victim Advocate privilege.

(2)I have the right to decline any or all SAPR services. I may also ask for a different SAPR VA if one is available.

(3)I have been advised to keep a signed and dated copy of this form for my records. This form may be used in other matters before other agencies (e.g., Department of Veterans Affairs) or for other lawful purposes. Restricted Reports: By signing this form I am giving consent that for Restricted Reports, this form will remain with the SARC for 50 years; if not requested, it will be retained, by policy, for 5 years (See block 8 below). Unrestricted Reports: By signing this form I am giving consent that for Unrestricted Reports, this form will be stored electronically in DSAID for 50 years.

2.CHOOSE A REPORTING OPTION (Initial)

a.I elect Unrestricted Reporting. I have decided to report that I am a victim of sexual assault to my command, law enforcement, or other military authorities for investigation of this crime. I understand that a Restricted Report is no longer available to me.

b.I elect Restricted Reporting. I have decided to confidentially report that I am a victim of sexual assault. Law enforcement or other military authorities will NOT be notified unless one of the exceptions applies. I understand the information I provide will NOT start an investigation or be used to hold the offender(s) accountable. I understand that I can switch to Unrestricted Reporting at any time.

RESTRICTED REPORT CASE NUMBER:

3.a. SIGNATURE OF VICTIM	b. DATE (YYYYMMDD)	4.a. SIGNATURE OF SARC/SAPR VA	b. DATE (YYYYMMDD)

5.I have reconsidered my previous selection of "Restricted Reporting" and am now choosing to make an Unrestricted Report.

EXCEPTIONS TO "RESTRICTED REPORTING"

There are exceptions to Restricted Reporting. This means that sometimes circumstances require that your Restricted Report of sexual assault must be disclosed. The following persons or organizations may be told about your sexual assault report for the following reasons:

1.Command officials or law enforcement when you provide written authorization.

2.Command officials or law enforcement to prevent or lessen a serious and imminent threat. This may be a threat to the health or safety of you or another person. Multiple reports involving the same alleged suspect may also meet this criteria.

3.Disability Evaluation Boards, Medical Evaluation Boards, and the officials participating in the boards. The report may be disclosed to these parties when it is required for fitness for duty or disability retirement determinations. Disclosure is limited to only that information necessary to make a determination for disability processing.

4.SARC, SAPR VA or healthcare personnel when required for the direct supervision of victim services.

5.Military or civilian courts when ordered, or if disclosure is required by Federal or state statute.

Before disclosing any information, SARCs, SAPR VAs and healthcare personnel will first consult with the servicing legal office. The legal office will determine if any of the above exceptions apply, if there is a duty to disclose the information, and who will make the disclosure when required.

6. VICTIM CONSENTED TO TRANSFER OF (RR/UR) CASE DOCUMENTS TO ANOTHER SARC: (X and complete as applicable)

Yes		No	If yes: Date (YYYYMMDD)		Location of Transfer:

7. VICTIM CONTACTED AT 1-YEAR MARK OF THE RESTRICTED REPORT: (X and complete as applicable)

8.a. VICTIM REQUESTED TO KEEP RESTRICTED REPORT DD FORM 2910 FOR 50 YEARS: (X one)

Yes		No

8.b. VICTIM REQUESTED TO KEEP RESTRICTED REPORT DD FORM 2911 FOR 50 YEARS: (X one)

Yes		No

9. VICTIM REQUESTED A SECOND COPY OF THE DD FORM 2910: (X and complete as applicable)

Yes		No	If yes: Date (YYYYMMDD)

10. VICTIM REQUESTED A COPY OF THE DD FORM 2911 FROM SAFE KIT. I FACILITATED THIS REQUEST: (X and complete as applicable)

Yes		No	If yes: Date (YYYYMMDD)

11. I understand that I cannot request an Expedited Transfer, a Military Protective Order, or a Civilian Protective Order through this form. (X one)

DD FORM 2910, MAY 2013

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