Form DD Form 2985 DD Form 2985 Department of Defense Sexual Assault Prevention and Resp

Per General Records Schedule DAA-0330-2016-0005, resolved case files are to be
cut off at the end of the calendar year and destroyed 25 year(s) after cut off.

DEPARTMENT OF DEFENSE
SEXUAL ASSAULT PREVENTION AND RESPONSE OFFICE (SAPRO)
REQUEST FOR SAPRO'S ASSISTANCE

OMB No.
OMB approval expires

The public reporting burden for this collection of information is estimated to average 30 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, East
Tower, Suite 03F09, Alexandria, VA 22350-3100 (XXXX-XXXX). 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 RETURN YOUR FORM TO THE ABOVE ADDRESS. Return form to Department of Defense, Sexual Assault Prevention and
Response Office, 4800 Mark Center Drive, Suite 07G21, Alexandria, VA 22350-8000 or by email at [email protected].

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1561 note, Improved Sexual Assault Prevention and Response in the Armed Forces; DoD Directive 6495.01, Sexual Assault
Prevention and Response (SAPR) Program; DoD Instruction 6495.02, Sexual Assault Prevention and Response (SAPR) Program Procedures.
PRINCIPAL PURPOSE(S): To track victim-related inquiries received by the Sexual Assault Prevention and Response Office (SAPRO) via e-mail,
SAPR.mil, the DoD Safe Helpline, phone, or postal service. Once received, inquiries are referred to the appropriate agency POC and/or to the DoD IG
in order to address the issue(s) raised and facilitate a resolution. This form does not constitute a report of a sexual assault.
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. Applicable Blanket
Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure to the Department of Justice for
Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, and Data Breach Remediation
Purposes Routine Use. The complete list of DoD Blanket Routine Uses can be found online at http://dpcld.defense.gov/Privacy/SORNsIndex/
BlanketRoutineUses.aspx. The applicable system of Records Notices is DHRA XX, DoD Sexual Assault Prevention and Response Office Victim
Assistance Data Systems at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/OSDJS-Article-List/

Needs DD67

DISCLOSURE: The completion of this form is voluntary. However, failure to provide information may result in the inability to provide requested
services.

SECTION I - INQUIRER TO USE
1. DATE (YYYYMMDD)
3. NAME: FIRST

2. WOULD YOU LIKE DOD SAPRO TO FOLLOW UP WITH YOU?
YES
NO
LAST:
4. RELATIONSHIP TO VICTIM/SURVIVOR

5. PREFER FOLLOW-UP BY:

E-MAIL

TELEPHONE

a. E-MAIL ADDRESS

EITHER

b. TELEPHONE NUMBER (Include Area Code)

c. OK to leave message?
YES

d. BEST TIME TO FOLLOW UP:
N/A
During working hours

After working hours

6. VICTIM/SURVIVOR INFORMATION

Between:

NO

EST

and

N/A
LAST:

a. NAME (If different from above): FIRST

b. SERVICE AFFILIATION

c. SERVICE STATUS
Active Duty
Air Force
Air National Guard
Retired
Army
Army National Guard
Marine Corps
Navy
Other:
7. INCIDENT INFORMATION
a. DATE OF INCIDENT
b. WAS IT REPORTED?

Reserve

Discharged

d. RANK
N/A

Dependent

c. YEAR REPORTED

(YYYYMMDD)

NO

YES

8. INQUIRY RELATED TO PROVIDING INFORMATION ABOUT:
a. CATEGORY (You may choose more than one.)
General Complaint
Feedback of SAPR Personnel or Program
Request for Referral
Regarding Retaliation
to Service
b. COMMENTS

General Information Request

Raising a Policy Issue

Information of Sexual Assault

Regarding Misconduct

9. DO YOU GIVE SAPRO PERMISSION TO FORWARD THIS FORM TO THE APPROPRIATE SERVICE OR AGENCY FOR FURTHER ACTION
IF DEEMED NECESSARY?
YES

NO

I would like to talk to someone first.

DD FORM 2985, 20170322 DRAFT

Adobe Designer 11

Per General Records Schedule DAA-0330-2016-0005, resolved case files are to be
cut off at the end of the calendar year and destroyed 25 year(s) after cut off.

SECTION II - RESPONSE
(For SAPRO, Safe Helpline, Service and/or Agency use only)
10. NAME OF STAFF RESPONDING TO INQUIRY

11. HOW WAS INQUIRY RECEIVED?
Safe Helpline

Telephone Call

SAPRO Website

E-mail

Letter

Other:

12. SUMMARY OF INQUIRY

Needs DD67

13.a. INQUIRER REFERRED TO

b. DATE (YYYYMMDD)

14. INQUIRY REFERRAL

(1) REFERRED FROM: a. TO AGENCY/SERVICE

c. DATE (YYYYMMDD)

d. SUSPENSE DATE (YYYYMMDD)

b. POINT OF CONTACT

e. FOLLOWED UP WITH SAPRO AND/OR INQUIRER?
YES

(2) REFERRED FROM: a. TO AGENCY/SERVICE

c. DATE (YYYYMMDD)

d. SUSPENSE DATE (YYYYMMDD)

c. DATE (YYYYMMDD)

d. SUSPENSE DATE (YYYYMMDD)

e. FOLLOWED UP WITH SAPRO AND/OR INQUIRER?

16. RESOLUTION

DD FORM 2985, 20170322 DRAFT

NO

N/A

b. POINT OF CONTACT

e. FOLLOWED UP WITH SAPRO AND/OR INQUIRER?
YES

15. COMMENTS

N/A

b. POINT OF CONTACT

YES
(3) REFERRED FROM: a. TO AGENCY/SERVICE

NO

NO

N/A