Form 2910 at a glance
What it is: DD FORM 2910 is the Victim Reporting Preference Statement: read the Privacy Act Statement before completing this form.
Who signs: The victim signs at 3.A. SIGNATURE OF VICTIM, and the SARC/SAPR VA signs at 4.A. SIGNATURE OF SARC/SAPR VA.
A filled-in Form 2910 example: a service member starts the statement
How to fill out Form 2910, box by box
Your full name, SSN and DoD Identification Number
Under 1. Reporting process and options discussed with the SAPR VA or SARC, write A. I, (full name), (SSN) and (DoD Identification Number).
Eligibility was explained: initial (1), (2), (3) and (4)
Under B. Eligibility was explained and the following information was provided, initial (1), (2), (3) and (4). (1) The services, protective orders, and reporting options that are available. (2) If my case is prosecuted in a civilian jurisdiction there will be different procedures, e.g. SAFE kit retention. (3) Eligibility for a Special Victims' Counsel or Victims' Legal Counsel (SVC/VLC) who will be my attorney and not the government's attorney. (4) The SARC/SAPR VA has informed me of available support services, to include mental health providers, and chaplain resources.
Prior to entry into military service
(5) Please initial here if this sexual assault occurred PRIOR TO ENTRY into military service (includes both as child or adult).
Home installation and SARC contact
(6)(a) Is this your home installation? Mark Yes or No. (b) If not, here is the contact information for your local SARC (name/phone number).
National Guard member and status
(7) In accordance with DoW policy, if reporting a sexual assault that occurred prior to or while not performing active or inactive training, National Guard and Reserve Component members are eligible to receive SAPR advocacy support services from a SARC and SAPR VA and are eligible to file both a Restricted or Unrestricted Report. (a) Are you a National Guard member? Mark Yes or No. (b) If so, what status are you on? Title 10 or Title 32.
Unrestricted Reporting: a crime which is investigated
C. UNRESTRICTED REPORTING (Initial): (1) Law enforcement, the Office of Special Trial Counsel (OSTC), and my command will be notified that I am a victim of a sexual assault. A Military Criminal Investigative Organization (MCIO) investigator (e.g. CID, NCIS, AFOSI) or the appropriate civilian law enforcement agency will investigate. I can receive medical treatment, support services, counseling, and a Sexual Assault Forensic Examination (SAFE) if indicated. A Case Management Group will track my Unrestricted Report and provide a status report. In a UCMJ case, I will be provided a DD Form 2701 (which contains important information about my rights as a victim) from law enforcement or MCIO. I should retain the DD Form 2701.
(2) Through a separate form, I may request an Expedited Transfer (temporary or permanent) from my installation or to a different location within my installation. (3) I may request a Military Protective Order (MPO).
Restricted Reporting: a crime which is not investigated
D. RESTRICTED REPORTING (Initial): (1) I may confidentially receive medical/mental health treatment, advocacy, and legal services. Law enforcement and my command will NOT be notified and the crime will NOT be investigated. No action will be taken against the suspect(s).
(3) I understand that state laws, local laws or international agreements may limit some or all DoW's Restricted Reporting protections. In the (state, city/county) of, civilian medical authorities must report the sexual assault when a victim reports or undergoes a SAFE.
(4) I may choose to have a SAFE. Evidence collected from my SAFE will be stored for 10 years from the date I sign this form, if the SAFE was conducted at a Military Treatment Facility. The DD Form 2911 will be retained for 50 years.
(6) Expedited transfers and protective orders against the suspect will NOT be available to me if I choose Restricted Reporting. I still have the option for SVC/VLC.
(8) I may change my Restricted Report to an Unrestricted Report, at any time. However, delays in changing my report from Restricted to Unrestricted could impact the investigation and judicial process.
Reporting option A: Unrestricted Reporting
2. CHOOSE A REPORTING OPTION (Initial either A. or B.) A. I elect Unrestricted Reporting. I have decided to report that I am a victim of sexual assault and I understand that my command, law enforcement, and other military authorities will be notified.
B. Restricted Reporting and the case number
B. I elect Restricted Reporting. Law enforcement or other military authorities will NOT be notified unless one of the exceptions applies. I understand that I can convert to Unrestricted Reporting at any time. Write the RESTRICTED REPORT CASE NUMBER.
B. Date and 4.A. Signature of SARC/SAPR VA
Each signature has its own B. DATE (YYYYMMDD), and 4.A. SIGNATURE OF SARC/SAPR VA has the second one.
More rules for Form 2910
E. The exceptions to Restricted Reporting have been explained to me. Mark Yes or No.
There are exceptions to Restricted Reporting. This means that sometimes circumstances require that your Restricted Report of sexual assault must be disclosed.
F. Other important considerations for Unrestricted and Restricted Reports (Initial): (1) If I do not sign this form, the SARC or SAPR VA will not inform investigators, commanders, or others about my sexual assault. (2) I have the right to decline any or all SAPR advocacy services.
(3) I have been advised to keep a signed and dated copy of this form for my records. Restricted Reports: By signing this form I am giving consent that for Restricted Reports, when applicable, this form will be stored electronically in DSAID for 50 years. 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.
5. CONVERSION: I have reconsidered my previous selection of Restricted Reporting and am now choosing to make an Unrestricted Report. A. SIGNATURE OF VICTIM, B. DATE (YYYYMMDD), C. SIGNATURE OF SARC/SAPR VA, D. DATE (YYYYMMDD).
6. My reason for converting my Restricted Report to an Unrestricted Reporting is: CATCH Program, or Other, please explain.
12. Department of Veterans Affairs Information, A.: I was advised that as a current Service member, I am eligible for Department of Veterans Affairs (VA) services for military sexual trauma (MST).
C. I am retiring or separating from the Armed Forces: Yes No. (1) If yes, I have been provided the name and contact information of the VHA MST Coordinator nearest to my residence. (2) If yes, I have been provided the name and contact information of the VBA MST Coordinator nearest to my residence.
13. Sexual Violence and Support Experiences Study: I understand that I can learn more about how to provide confidential feedback about my experiences with the military response system and the support I receive by visiting www.SAPR.mil/SVSES. Participation is my choice.
14. Confirmation That Victim Did Not Previously Submit A Catch Entry On This Same Suspect For This Same Sexual Assault: A. I confirm that I have not submitted another CATCH entry on this same suspect for this same sexual assault through a CATCH SRI Entry using DD Form 2910-4.
15. Information regarding the Catch a Serial Offender (CATCH) Program: A. I have been informed about and elect: To participate in the CATCH Program. Not to participate in the CATCH Program. B. I have been informed that additional information on the CATCH program can be found at www.SAPR.mil/CATCH
Common questions about Form 2910
Who signs it?
The victim signs at 3.A. SIGNATURE OF VICTIM, and the SARC/SAPR VA signs at 4.A. SIGNATURE OF SARC/SAPR VA.
Sources
[1] DD Form 2910 (NOV 2021), Victim Reporting Preference Statement, Department of War (the Official source link on this page).