DD 2910 Victim Reporting Preference Statement

OMB No. 0704-0482
OMB approval expires

VICTIM REPORTING PREFERENCE STATEMENT
(Read Privacy Act Statement before completing this form.)

The public reporting burden for this collection of information is estimated to average 90 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 aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0482). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number. PLEASE DO NOT MAIL, FAX, OR EMAIL THIS FORM. STORE COMPLETED FORM IN ACCORDANCE WITH DODI 6495.02.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C.
8013, Secretary of the Air Force; 32 U.S.C. 102, National Guard; DoD Directive 6495.01, Sexual Assault Prevention and Response (SAPR) Program; DoD Instruction 6495.02,
SAPR Program Procedures; Army Regulation 600-20, Chapter 8, Army Command Policy (SAPR Program); Secretary of the Navy Instruction 1752.4B, Sexual Assault Prevention
and Response; Marine Corps Order 1752.5B, SAPR Program; Air Force Instruction 90-6001, SAPR Program; 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/SORNsIndex/tabid/5915/Article/6841/dhra-06-dod.aspx).
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To permit the disclosure of records of closed
cases of unrestricted reports to the Department of Veterans Affairs (DVA) for purpose of providing medical care to former Service members and retirees, to determine the eligibility
for or entitlement to benefits, and to facilitate collaborative research activities between the DoD and DVA. Applicable Blanket Routine Use(s) are: (1) Law Enforcement Routine
Use, (2) Disclosure When Requesting Information Routine Use, (3) Disclosure of Requested Information Routine Use, (4) Congressional Inquiries, (8) Disclosure to the Office
Personnel Management Routine Use, (9) Disclosure to the Department of Justice for Litigation Routine Use, (12) Disclosure of Information to the National Archives and Records
Administration Routine Use, (13) Disclosure to the Merit systems Protection Board Routine Use, and (15) Data Breach Remediation Purposes Routine Use. The DoD Blanket
Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of
DoD Blanket Routine Uses can be found Online at: http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.
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 advocacy services or healthcare (medical and mental health) if you selected the Restricted
Reporting option. The Social Security Number (SSN) is one of several unique personal identifiers that may be provided. This form will be retained for 50 years.

1. REPORTING PROCESS AND OPTIONS DISCUSSED WITH THE SAPR VA OR SARC
a. I, (full name)

DSAID CASE NUMBER:

(Social Security Number)

and (DoD Identification 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.
INITIALS

(1) The SARC or SAPR VA has explained to me the services, protective orders, and reporting options that are available to me.
(2) The SARC or SAPR VA explained to me that if my case is prosecuted in a civilian jurisdiction there will be different procedures in place, e.g.,
SAFE kit retention and DD Form 2701.
(3) Please initial here if this sexual assault occurred PRIOR TO ENTRY into military service. (Iincludes both as a child or adult.)
b. UNRESTRICTED REPORTING - REPORTING A CRIME WHICH IS INVESTIGATED.
(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 a Military Criminal Investigation Organization (MCIO) investigator (e.g. CID, NCIS, AFOSI) or the appropriate civilian law enforcement agency. I can receive medical treatment, support services, and counseling. I can also choose to have a Sexual Assault Forensic
Examination (SAFE) if indicated. In a UCMJ case, I will be provided a DD Form 2701 (which contains important information about my rights as
a victim) from the law enforcement agency or MCIO. I should retain the DD Form 2701. In accordance with DoD policy, if reporting a sexual
assault that occurred prior to or while not performing active service or inactive training, active duty, National Guard and Reserve Component
members are eligible to receive SAPR advocacy support services from a SARC and a SAPR VA and are eligible to file both a Restricted or an
Unrestricted Report.
(2) In accordance with DoD Instruction (DoDI) 6495.02, as a service member, I understand that (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) Depending on the facts of my case, I may request a Military Protective Order (MPO). If a written and/or verbal MPO is issued against a
service member, my commander will provide me with a copy of the DD Form 2873.

N E E D S

D D

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(4) I also have the option of requesting a Civilian Protective Order (CPO) from civilian courts.
(5) If the crime is prosecuted under the Uniform Code of Military Justice (UCMJ), any confidential communication with my SARC or SAPR VA are
privileged 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 may confidentially receive medical treatment, advocacy services, legal services, and counseling. I may also choose to have
a Sexual Assault Forensic Examination (SAFE), 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 alleged 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 advocacy support services from a SARC and a SAPR VA and are eligible to file both a Restricted Report and an
Unrestricted 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 disclosed.
(3) I understand the evidence collected from my SAFE will be stored for 5 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. If the evidence is collected by a civilian healthcare facility, the
civilian healthcare facility will handle the SAFE kit storage in accordance with the established Memorandum of Understanding (MOU) with the
DoD. I will be contacted in 1 year by my SARC to discuss my options as they relate to this evidence. If the SAFE was conducted by a civilian
facility with no formal MOU with DoD, then the SAFE kit will be handled in accordance with state and local laws.
(4) I understand that state laws, local laws or international agreements may limit some or all of DoD's Restricted Reporting protections.

DD

In the (state, city/county) of ______________________________________________ , medical authorities must report the sexual assault to
_________________________________________________ .
(5) I understand that the SARC will provide information that does not reveal my identity, nor that of my alleged offender, to the installation
commander. This notification takes place within 24 hours of my Restricted Report. If I may be 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 a Military Protective Order and/or a Civilian Protective Order against the alleged offender,
or an Expedited Transfer and my victim's rights, may NOT be available to me if I choose Restricted Reporting.
Adobe Designer 9.0
PREVIOUS EDITION IS OBSOLETE.
FORM 2910, 20151103 DRAFT

1.c. RESTRICTED REPORTING (Continued)
INITIALS

(7) I understand that speaking to others about my sexual assault may result in the crime being reported to command and law enforcement if those
persons are not authorized to accept Restricted Reports as set forth in DoDI 6495.02. Communications with chaplains and lawyers may be
protected to the extent authorized by law.
(8) I understand that I may change my Restricted Report to 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.
(9) I understand that I can participate in the "Catch a Serial Offender" (CATCH) Program (while retaining my Restricted Report).

d. OTHER IMPORTANT CONSIDERATIONS FOR UNRESTRICTED AND RESTRICTED REPORTS
(1) I understand that 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 understand that 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 be retained for 50 years, as required
by law. For Restricted Reports, the law requires that this form is retained in a manner that protects confidentiality.
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. For Unrestricted Reports, access to it will be limited to persons with an official need to know.
(4) I understand that I cannot request an Expedited Transfer, a Military Protective Order, or a Civilian Protective Order through this form.
(5) I understand that I am eligible for a Special Victims Counsel, who will be my attorney and not the government's attorney, and who will provide
me with legal advice and representation.
(6) I understand that if I experience coercion, retaliation, reprisal, or ostracism from my supervisors or peers, I can report it to the SARC, Special
Victims Counsel, my commander, Victim Witness Assistance Program personnel or my Service Inspector General.
(7) I understand that I can also request a defense counsel to advise and assist me in the event that there is evidence that I committed misconduct
around the time of the sexual assault allegation (for example, underage drinking).
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 alleged offender(s) appropriately accountable. I understand that I can convert 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

N E E D S

D D

b. DATE (YYYYMMDD)

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5. 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)

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 criterion.
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 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.
Yes

No

The exceptions to Restricted Reporting have been explained to me.

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)
Yes

No

If yes: Date (YYYYMMDD)

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

Yes

No If yes: Date (YYYYMMDD)

DD FORM 2910, 20151103 DRAFT

If not, document how the SARC attempted to locate the victim:

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

No

If yes: Date (YYYYMMDD)
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