Form DD Form 2965 DD Form 2965 Defense Sexual Assault Incident Database (DSAID) Data Fo

CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

OMB No. 0704-0482
OMB approval expires
YYYYMMDD

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM

The public reporting burden for this collection of information is estimated to average 1 hour 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, at [email protected]. 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, EMAIL OR STORE THIS FORM. DISPOSE OF COMPLETED FORM AS DIRECTED AT THE TOP OF EACH PAGE.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 8013, Secretary of the Navy; 10 U.S.C. 9013, Secretary
of the Air Force; 32 U.S.C. 102, National Guard; DoD Directive 6495.01, SAPR Program; DoD Instruction 6495.02, SAPR Program Procedures; Army Regulation 600-20, Chapter 7, Army
Command Policy (SAPR Program); OPNAV Instruction 1752.1C, SAPR Program; Marine Corps Order 1752.5C, SAPR Program; Air Force Instruction 90-6001, SAPR Program; and E.O. 9397
(SSN), as amended.
PRINCIPAL PURPOSE(S): To centralize case-level sexual assault data involving a member of the Armed Forces, in a manner consistent with statute and DoD regulations for Unrestricted and
Restricted reporting. To facilitate reports to Congress on claims of retaliation in connection with an Unrestricted Report of sexual assault made by or against a member of the Armed Forces.
Records may also be used as a management tool for statistical analysis, tracking, reporting, evaluating program effectiveness, conducting research, and case and business management. Deidentified data may also be used to respond to mandated reporting requirements. The DSAID File Locker, a separate module within the system, is used to maintain Victim Reporting Preference
Statements and DoD Sexual Assault Forensic Examinations (SAFEs) to ensure compliance with federal records retention requirements and allow Victims and reporters access to these forms for
potential use in Department of Veterans Affairs (DVA) benefits applications. https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DHRA-06-DoD.pdf
ROUTINE USE(S): Information provided may be further disclosed to the Department of Veterans Affairs (DVA) for benefits purposes and to facilitate collaborative research activities between the
DoD and DVA. In addition, this form is subject to the proper and necessary routine uses identified in the system of records notice(s) specified in the purpose statement above. In addition to those
disclosures generally permitted in accordance with 5 U.S.C. 552a(b), the records contained herein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as
follows:
a. To permit the disclosure of records of closed cases of Unrestricted Reports to the DVA for purpose of providing mental health and 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. b. To contractors responsible for performing or working on
contracts for the DoD when necessary to accomplish an agency function related to this System of Records. Individuals provided information under this routine use are subject to the same Privacy
Act requirements and limitations on disclosure that apply to DoD officers and employees. c. To any component of the Department of Justice for the purpose of representing the DoD, or its
components, officers, employees, or members in pending or potential litigation to which the record is pertinent. d. In an appropriate proceeding before a court, grand jury, or administrative or
adjudicative body or official, when the DoD or other Agency representing the DoD determines that the records are relevant and necessary to the proceeding; or in an appropriate proceeding before
an administrative or adjudicative body when the adjudicator determines the records to be relevant to the proceeding. e. To the National Archives and Records Administration or the purpose of
records management inspections conducted under the authority of 44 U.S.C. 2904 and 2906. f. To a Member of Congress or staff acting upon the Member’s behalf when the Member or staff
requests the information on behalf of, and at the request of, the individual who is the subject of the record. g. To appropriate agencies, entities, and persons when (1) the DoD suspects or has
confirmed that there has been a breach of the System of Records; (2) the DoD has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, the DoD
(including its information systems, programs, and operations), the Federal Government, or national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably
necessary to assist in connection with the DoD’s efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm. h. To another Federal agency or Federal
entity, when the DoD determines that information from this System of Records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach
or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs and operations), the Federal Government, or
national security, resulting from a suspected or confirmed breach.
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. For Unrestricted Reports, the Social Security Number (SSN) is one of several unique
personal identifiers that may be provided. Some alternatives include state driver's license number, passport number, or DoD ID number.

HOW TO USE THIS FORM
Fields on this form should only be completed as needed to fulfill DSAID data requirements for the given type of report (Restricted or Unrestricted); that is, for Restricted Reports no personally
identifiable information for Victims (except for the Encryption Key information as described below) or subjects should be captured. In the event that a SARC does not have immediate access to
DSAID, this form may be used in the interim to capture the adult sexual assault Victim's information. The information captured on this form shall be entered in DSAID within the timeline established
in DoD Instruction (DoDI) 6495.02. In accordance with General Records Schedule (GRS) 5.2, 020, Intermediary Records, and the business use established in DoDI 6495.02, this form shall be
destroyed upon verification of successful creation of the information in DSAID or when no longer needed for business use, whichever is later. The form shall NOT be maintained longer than required
to input all information required into DSAID per the authorities above. Until such time as the form is destroyed, the form should be covered with a DD Form 2923, “Privacy Act Data Cover Sheet”,
and maintained under double-lock-and-key when not under the direct control of an individual with a need-to-know. For Restricted Reports, the data for the Encryption Key (see Section I, Block 4), is
necessary to maintain privacy and security of DD Forms 2910 and DD Form 2911 in a Restricted Report (RR). Any victim filing a RR may be asked to provide this information when his/her RR is
transferred or to access the forms stored electronically in the File Locker. For select definitions of terminology used below, please see the DSAID User Manual. This form cannot be used in place of
DD Forms 2910, 2910-1, or 2910-2 to officially report sexual assault, lost forms, and related retaliation, respectively.

SECTION I - DSAID CASE INFORMATION
1. DSAID CONTROL NUMBER

2. TYPE OF REPORT (X one)

RR-

RESTRICTED

UU-

UNRESTRICTED

3. SARC PRIMARY LOCATION (DSAID LOCATION CODE)

4. ENCRYPTION KEYS (For Restricted Report only)
a. VICTIM DATE OF BIRTH
(MM/DD/YYYY)

b. VICTIM MOTHER’S MAIDEN NAME

5.a. AGE AT TIME OF INCIDENT
(For Restricted Report only)

6.a. DSAID CASE STATUS (X one)
OPEN

c. VICTIM STATE/COUNTRY OF BIRTH

b. DATE VICTIM SIGNED FORM ELECTING TO
CONVERT FROM RR TO RU (if applicable)
(MM/DD/YYYY)

d. LAST 4 OF VICTIM SSN

c. RUd. CONVERSION REASON (If known or available)

b. EXPLANATION FOR OPEN WITH LIMITED INFORMATION STATUS (If applicable)

CLOSED

OPEN WITH LIMITED INFORMATION

VICTIM REFUSED/DECLINED SERVICES

VICTIM OPT-OUT OF PARTICIPATING IN INVESTIGATIVE PROCESS

LOCAL JURISDICTION REFUSED TO PROVIDE VICTIM INFORMATION

CIVILIAN VICTIM WITH MILITARY SUBJECT

7. RESTRICTED REPORT REASON

DD FORM 2965, DRAFT 20211014

8. DATE OF REPORT TO DOD
(MM/DD/YYYY)

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

Controlled by:
CUI Category:
LDC:
POC:

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CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
9. RESTRICTED REPORT EXCEPTION APPLIED (X as applicable)

YES

IF YES, REASON FOR EXCEPTION:

NO

DISCLOSURE IS AUTHORIZED BY VICTIM IN WRITING.
DISCLOSURE IS NECESSARY TO PREVENT OR LESSEN A SERIOUS OR IMMINENT THREAT TO HEALTH OR SAFETY OF THE VICTIM OR ANOTHER
PERSON.
DISCLOSURE BY A HCP IS REQUIRED FOR FITNESS FOR DUTY FOR DISABILITY RETIREMENT DETERMINATIONS.
DISCLOSURE IS REQUIRED FOR SARC, VA, OR HCP TO PROVIDE SUPERVISION AND/OR COORDINATION OF DIRECT VICTIM TREATMENT OR SERVICES.
COMMUNICATE WHEN DISCLOSURE IS ORDERED BY A JUDGE, OR OTHER OFFICIALS OR ENTITIES AS REQUIRED BY A FEDERAL OR STATE STATUTE
OR APPLICABLE U.S. INTERNATIONAL AGREEMENT.

10. VICTIM NAME: a. LAST

b. FIRST

c. MIDDLE

11. ID TYPE (X one)
DOD ID NUMBER

SSN

PASSPORT NUMBER

ALIEN REGISTRATION

FOREIGN COUNTRY ID

UNKNOWN

ID NUMBER:

12.a. VA ASSIGNED (X one)
YES

b. IF YES, VA NAME:

c. IF NO, REASON:

NO

SECTION II - VICTIM INFORMATION (At time of Report, unless otherwise indicated)
13. DATE VICTIM INFORMED OF OPTIONS (MM/DD/YYYY)

14. DATE VICTIM SIGNED DD FORM 2910 (MM/DD/YYYY)

15. RELATIONSHIP TO SUBJECT(S) (X all that apply)
FRIEND

NEIGHBOR

ACQUAINTANCE

EMPLOYER

STRANGER

RELATIONSHIP UNKNOWN

16.a. COMMANDER NAME

LOVE INTEREST/DATING

EXTENDED FAMILY MEMBER

SUPERVISOR/COMMAND

b. COMMAND NOTIFICATION
ACCOMPLISHED WITHIN 24
HOURS (X one)
YES

RECRUITER

OTHERWISE KNOWN

COWORKER

EMPLOYEE

c. IF NO, REASON:

NO

17. INCIDENT OCCURRED: (X as applicable)
a. INCIDENT OCCURRED ON DEPLOYMENT?
YES

b. INCIDENT OCCURRED ON TDY?

NO

YES

c. INCIDENT OCCURRED ON LEAVE?

NO

YES

NO

18. DOES LOCATION REQUIRE MANDATORY REPORTING FOR MEDICAL CARE FOR A SEXUAL ASSAULT? (X one)
19. DATE OF BIRTH
(MM/DD/YYYY)

20. GENDER (X one)

21. ETHNICITY (X one)

FEMALE

NO

22. RACE (X one)

HISPANIC OR LATINO

MALE

YES

AMERICAN INDIAN OR ALASKA NATIVE

WHITE

ASIAN

NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER

NOT HISPANIC OR LATINO

BLACK OR AFRICAN AMERICAN

UNKNOWN/CHOOSES NOT
TO DISCLOSE

UNKNOWN/CHOOSES NOT TO DISCLOSE

23. VICTIM TYPE (X one) (For adult dependents, select U.S. Civilian and complete Block 24, 26, 27, 28, and 29.)
MILITARY

DOD CIVILIAN

OTHER GOVT. CIVILIAN

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

DOD CONTRACTOR

24. VICTIM AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

COAST GUARD

DOD

NOAA

PUBLIC HEALTH

N/A

25. VICTIM STATUS
a. IF MILITARY, VICTIM DUTY STATUS (X one)
ACTIVE DUTY

b. VICTIM RECRUIT/TRAINING STATUS (X one)

NATIONAL GUARD (NG)

RESERVE

YES

c. (1) IF VICTIM DUTY STATUS IS NG, TYPE OF NATIONAL GUARD SERVICE (X one):

NO
TITLE 10

TITLE 32

(2) VICTIM NG STATE AFFILIATION (X one)
50 STATES (ENTER STATE):

DISTRICT OF COLUMBIA

PUERTO RICO

(3) VICTIM NG TITLE 10 CATEGORY (X one)

NATIONAL GUARD

ACTIVE DUTY ARMED SERVICES

GUAM

VIRGIN ISLANDS
RESERVISTS

(4) VICTIM NG TITLE 32 CATEGORY (X one)
ACTIVE GUARD AND RESERVE (AGR)

TRADITIONAL/M DAY

TECHNICIAN/DUAL STATUS

TECHNICIAN/NON-DUAL STATUS

NOT IN DUTY STATUS

(5) IF VICTIM IS TITLE 32 AND VICTIM RECRUIT/TRAINING STATUS IS YES, NG VICTIM RECRUIT/TRAINING STATUS (X one)
NG PRE-ACCESSION RECRUIT SUSTAINMENT PROGRAM (RSP)

PRE-RECRUIT GENERAL EDUCATION DEVELOPMENT (GED) PROGRAM

d. IF VICTIM IS DOD CIVILIAN/OTHER GOVERNMENT CIVILIAN: PAY PLAN (X one)
GS

WG

NAF

SES

f. VICTIM ASSIGNED LOCATION

DD FORM 2965, DRAFT 20211014

OTHER

e. IF VICTIM IS MILITARY/CIVILIAN, PAY GRADE

UNKNOWN

g. VICTIM ASSIGNED UIC

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

h. VICTIM ASSIGNED UNIT NAME

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CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
i. IF GUARD OR RESERVE, WAS LINE OF DUTY (LOD) INITIATED? (X one)

YES

IF NO, X REASON:

NO

VICTIM DID NOT WANT LOD INITIATED

NO INFORMATION AVAILABLE FROM ACTIVE DUTY SARC

ASSAULT DID NOT OCCUR IN DUTY STATUS

OTHER

LOD NOT OFFERED

26. VICTIM CONTACT INFORMATION (Address/Telephone/Email)

27. IF NOT MILITARY, VICTIM DEPENDENT STATUS (X one)
YES - MILITARY DEPENDENT

YES - DOD CIVILIAN (OCONUS) DEPENDENT

NO

28. VICTIM DEPENDENT RELATIONSHIP (X one)
SPOUSE

ADULT CHILD

PARENT

29. WAS THE VICTIM IN THE MILITARY AT THE TIME OF THE ASSAULT? (X one)

YES

NO

SECTION III - VICTIM SAFETY (For multiple instances, reuse as needed)
30.a. VICTIM SAFETY ASSESSMENT COMPLETED? (X and complete as applicable)

YES

NO

b. IF YES, WAS A VICTIM SAFETY CONCERN IDENTIFIED? (X one)

YES

NO

c. IF YES, VICTIM SAFETY CONCERN NOTES(S)

d. VICTIM SAFETY CONCERN NOTE DATE (MM/DD/YYYY)
f. VWAP (DD Form 2701) PROVIDED (X one)

e. IF A VICTIM SAFETY ASSESSMENT WAS NOT COMPLETED, WHAT WAS THE REASON?
31. VICTIM INFORMED OF RIGHT TO REQUEST EXPEDITED TRANSFER? (X one)

c. MPO ISSUED (X one)

d. MPO ISSUE DATE
(MM/DD/YYYY)

YES

YES

NO

NO

33.a. MILITARY PROTECTIVE ORDER (MPO) REQUESTED? (X and complete as applicable)
b. MPO REQUEST DATE
(MM/DD/YYYY)

NO

b. IF YES, EFFECTIVE DATE OF CPO (MM/DD/YYYY)

YES

32.a. CIVILIAN PROTECTIVE ORDER (CPO) REQUESTED?
(X and complete as applicable)

YES

YES

NO

IF YES:

NO

e. MPO VIOLATED (X one)

f. IF YES, BY WHOM? (X one)

YES

VICTIM

NO

BOTH

SUBJECT

34. VICTIM EXPEDITED TRANSFER
a. DATE VICTIM REQUESTED EXPEDITED TRANSFER (MM/DD/YYYY)

b. VICTIM EXPEDITED TRANSFER REQUESTED TYPE (X one)

c. COMMAND DECISION FOR EXPEDITED TRANSFER (X one)

d. REASON FOR DISAPPROVED EXPEDITED TRANSFER PER COMMAND
DECISION

LOCAL - UNIT/DUTY TRANSFER

APPROVE

DISAPPROVE

PCS - INSTALLATION TRANSFER

e. DATE OF COMMAND DECISION FOR EXPEDITED TRANSFER
(MM/DD/YYYY)
f. VICTIM TRANSFERRED PER
COMMAND DECISION? (X one)
YES

g. VICTIM REQUESTED REVIEW FOR
EXPEDITED TRANSFER? (X one)

NO

YES

NO

h. SENIOR LEVEL DECISION FOR EXPEDITED
TRANSFER? (X one)
APPROVE

DISAPPROVE

j. VICTIM TRANSFERRED PER SENIOR LEVEL COMMAND DECISION?
(X one)

i. DATE OF SENIOR LEVEL DECISION FOR EXPEDITED TRANSFER
(MM/DD/YYYY)

YES

NO

SECTION IV - REFERRAL SUPPORT (For multiple instances, reuse as needed)
35.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

MENTAL HEALTH

LEGAL

CHAPLAIN/SPIRITUAL SUPPORT

VICTIM ADVOCATE/UNIFORMED VICTIM ADVOCATE

DOD SAFE HELPLINE

RAPE CRISIS CENTER

OTHER (Specify)

CIVILIAN

c. DATE OF REFERRAL
(MM/DD/YYYY)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

DD FORM 2965, DRAFT 20211014

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

Page 3 of 9

CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
36.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

MENTAL HEALTH

LEGAL

c. DATE OF REFERRAL
(MM/DD/YYYY)

CHAPLAIN/SPIRITUAL SUPPORT

VICTIM ADVOCATE/UNIFORMED VICTIM ADVOCATE

DOD SAFE HELPLINE

RAPE CRISIS CENTER

OTHER (Specify)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

37.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

MENTAL HEALTH

LEGAL

c. DATE OF REFERRAL
(MM/DD/YYYY)

CHAPLAIN/SPIRITUAL SUPPORT

VICTIM ADVOCATE/UNIFORMED VICTIM ADVOCATE

DOD SAFE HELPLINE

RAPE CRISIS CENTER

OTHER (Specify)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

38.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

MENTAL HEALTH

LEGAL

c. DATE OF REFERRAL
(MM/DD/YYYY)

CHAPLAIN/SPIRITUAL SUPPORT

VICTIM ADVOCATE/UNIFORMED VICTIM ADVOCATE

DOD SAFE HELPLINE

RAPE CRISIS CENTER

OTHER (Specify)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

SECTION V - FORENSIC EXAM
39. WAS FORENSIC EXAM OFFERED? (X one)

YES

NO

IF NO, REASON:

40.a. WAS FORENSIC EXAM COMPLETED? (X and complete as applicable)
b. IF YES: (1) LOCATION OF FORENSIC EXAM:
ON INSTALLATION

OFF INSTALLATION

YES

NO

(2) DATE OF EXAM (MM/DD/YYYY) c. IF NO, WAS IT BECAUSE SAFE KIT AND/OR
OTHER NEEDED SUPPLIES NOT AVAILABLE?

YES
NO

(3) STORAGE LOCATION OF SAFE KIT

41. RESTRICTED REPORT CONTROL NUMBER (For Restricted Report only)

SECTION VI - INVESTIGATIVE AGENCY
42.a. INVESTIGATIVE CASE FILE OPENED: (X and complete as applicable)
b. IF YES, INVESTIGATIVE CASE NUMBER*

YES

NO

c. INITIAL INVESTIGATIVE AGENCY LOCATION

*REFER TO THE DSAID SUPPORT PAGE FOR CURRENT INVESTIGATIVE CASE NUMBER FORMATS.
d. IF NO, PROVIDE A REASON (X and complete as applicable)
INCIDENT OCCURRED PRIOR TO VICTIM'S MILITARY SERVICE
INCIDENT BEYOND STATUTE OF LIMITATIONS

ALLEGED PERPETRATOR NOT SUBJECT TO UCMJ

OTHER (Specify)

43. AGENCY CONDUCTING INVESTIGATION (X one)
NCIS

AFOSI

ARMY CID

DD FORM 2965, DRAFT 20211014

NG/JA/OCI

CGIS

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

CIVILIAN LAW ENFORCEMENT

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CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
44. DATE INVESTIGATIVE ACTIVITY OPENED 45. INVESTIGATIVE ACTIVITY COMPLETED (X and complete as applicable)
(MM/DD/YYYY)
IF YES, DATE INVESTIGATIVE ACTIVITY COMPLETED (MM/DD/YYYY)
YES
NO

SECTION VII - INVESTIGATIVE AGENCY CASE TRANSFER (If applicable)
46. INVESTIGATIVE AGENCY CASE TRANSFERRED (X one)
ACROSS SERVICES

47. ASSOCIATED INVESTIGATIVE CASE NUMBER (See format instructions above)

WITHIN SERVICES

TO NON-MILITARY JURISDICTION

48. INVESTIGATIVE AGENCY CASE
TRANSFER DATE (MM/DD/YYYY)

49. AGENCY CONDUCTING INVESTIGATION (X one)
NCIS

AFOSI

ARMY CID

NG/JA/OCI

CGIS

CIVILIAN LAW ENFORCEMENT

50. GAINING INVESTIGATIVE AGENCY LOCATION

SECTION VIII - SUBJECT INFORMATION (For multiple subjects, reuse as needed.)
51. RESTRICTED REPORT: SUBJECT TYPE (X one)
MILITARY - CADET/MIDSHIPMAN/PREP SCHOOL STUDENT
OTHER GOVT. CIVILIAN

U.S. CIVILIAN

MILITARY - NON CADET/MIDSHIPMAN/PREP SCHOOL STUDENT

FOREIGN NATIONAL

FOREIGN MILITARY

DOD CIVILIAN

DOD CONTRACTOR

UNKNOWN

UNRESTRICTED REPORT:
52. SUBJECT NAME: a. LAST

b. FIRST

c. MIDDLE

53. ID TYPE (X one)
SSN

PASSPORT NUMBER

54. DATE OF BIRTH
(MM/DD/YYYY)

ALIEN REGISTRATION

56. GENDER (X one)

55. AGE AT TIME
OF INCIDENT

MALE
FEMALE

FOREIGN COUNTRY ID

57. ETHNICITY (X one)

UNKNOWN

ID NUMBER:

UNKNOWN

58. RACE (X one)

HISPANIC OR LATINO

AMERICAN INDIAN OR ALASKA NATIVE

NOT HISPANIC OR LATINO

BLACK OR AFRICAN AMERICAN

UNKNOWN

UNKNOWN

ASIAN

59. DEPENDENT STATUS
(X one)

WHITE

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

YES

NO

60. SUBJECT TYPE (X one)
MILITARY

DOD CIVILIAN

OTHER GOVERNMENT CIVILIAN

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

DOD CONTRACTOR

UNKNOWN

61. SERVICE AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

DOD

COAST GUARD

NOAA

PUBLIC HEALTH

UNKNOWN

62.a. DUTY STATUS (X one if applicable)
ACTIVE DUTY

NATIONAL GUARD (NG)

RESERVE

UNKNOWN

b. IF SUBJECT DUTY STATUS IS NG:
(1) SUBJECT NATIONAL GUARD SERVICE (X one)

(2) SUBJECT NG STATE AFFILIATION (X one)

TITLE 10

50 STATES (ENTER STATE):

TITLE 32

PUERTO RICO

(3) SUBJECT NG TITLE 10 CATEGORY (X one)

DISTRICT OF COLUMBIA
GUAM

ACTIVE GUARD AND RESERVE (AGR)

VIRGIN ISLANDS

ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)

ANNUAL TRAINING (AT)

ACTIVE DUTY ARMED SERVICES

BASIC TRAINING

MOBILIZED OCONUS

MOBILIZED CONUS

PROFESSIONAL MILITARY EDUCATION (PME)

(4) SUBJECT NG TITLE 32 CATEGORY (X one)
ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)
ROTC

STATE ACTIVE DUTY (SAD)

ACTIVE GUARD AND RESERVE (AGR)

TECHNICAL/ADVANCED INDIVIDUAL TRAINING (AIT)

ANNUAL TRAINING (AT)

PROFESSIONAL MILITARY EDUCATION (PME)

NOT IN DUTY STATUS

RESERVISTS
INACTIVE DUTY TRAINING (IDT)

RECRUIT SUSTAINMENT PROGRAM/STUDENT FLIGHT

TECHNICIAN DUAL STATUS

TECHNICIAN NON DUAL STATUS

(5) NG SUBJECT RECRUIT/TRAINING STATUS (X one)
NG PRE-ACCESSION RECRUIT SUSTAINMENT PROGRAM (RSP)

c. IF SUBJECT IS MILITARY/CIVILIAN, PAY GRADE

PRE-RECRUIT GENERAL EDUCATION DEVELOPMENT (GED) PROGRAM

N/A

d. SUBJECT DUTY ASSIGNMENT (X one)
RECRUITER

INSTRUCTOR

DRILL SERGEANT

DRILL INSTRUCTOR

N/A

e. IF SUBJECT IS DOD CIVILIAN/OTHER GOVERNMENT CIVILIAN: PAY PLAN (X one)
GS

WG

NAF

f. SUBJECT ASSIGNED LOCATION

DD FORM 2965, DRAFT 20211014

SES

OTHER

g. SUBJECT ASSIGNED UNIT NAME

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

UNKNOWN

h. SUBJECT ASSIGNED UIC
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Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION IX - INCIDENT DETAIL
63.a. FOR RESTRICTED REPORT, IS DATE OF INCIDENT KNOWN (X and complete as applicable)

YES

NO

c. IS DATE AN ESTIMATE? (X one)

b. IF YES, DATE OF INCIDENT (MM/DD/YYYY)

YES

NO

64. FOR UNRESTRICTED REPORT:
b. IS DATE AN ESTIMATE? (X one)

a. DATE OF INCIDENT (MM/DD/YYYY)

YES

NO

65. INCIDENT TIME OF DAY
66.a. INCIDENT LOCATION (X one)
ON MILITARY INSTALLATION/SHIP (OTHER THAN ACADEMY GROUNDS)

ON ACADEMY GROUNDS

OFF MILITARY INSTALLATION/SHIP/ACADEMY GROUNDS

UNIDENTIFIED

b. TYPE OF LOCATION (For example, private vehicle or hotel)

c. INCIDENT LOCATION NAME

d. STATE/COUNTRY

e. CITY

67. FOR VICTIM AND/OR SUBJECT: (X as applicable)
a. WAS ALCOHOL INVOLVED?

YES

68. WEAPONS USED? (X as applicable)

NO

UNKNOWN

YES

NO

b. WERE DRUGS INVOLVED?

YES

NO

UNKNOWN

UNKNOWN

69. TYPE(S) OF OFFENSE INVESTIGATED
a. FOR INCIDENTS OCCURRED PRIOR TO OCTOBER 1, 2007: (X as applicable)
RAPE (ART. 120)

INDECENT ASSAULT (ART. 134)

FORCIBLE SODOMY (ART. 125)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

UNKNOWN (NG ONLY)

PROSECUTED BY STATE LAW (NG ONLY)

b. FOR INCIDENTS OCCURRED ON OR AFTER OCTOBER 1, 2007 AND BEFORE JUNE 28, 2012: (X as applicable)
RAPE (ART. 120)

AGGRAVATED SEXUAL ASSAULT (ART. 120)

WRONGFUL SEXUAL CONTACT (ART. 120)
UNKNOWN (NG ONLY)

AGGRAVATED SEXUAL CONTACT (ART. 120)

FORCIBLE SODOMY (ART. 125)

ABUSIVE SEXUAL CONTACT (ART. 120)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

INDECENT ASSAULT (ART.134)

PROSECUTED BY STATE LAW (NG ONLY)

c. FOR INCIDENTS OCCURRED ON OR AFTER JUNE 28, 2012 AND BEFORE JANUARY 1, 2019: (X as applicable)
RAPE (ART. 120)

SEXUAL ASSAULT (ART. 120)

FORCIBLE SODOMY (ART. 125)

AGGRAVATED SEXUAL CONTACT (ART. 120)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

ABUSIVE SEXUAL CONTACT (ART. 120)

UNKNOWN (NG ONLY)

PROSECUTED BY STATE LAW (NG ONLY)

d. FOR INCIDENTS OCCURRED ON OR AFTER JANUARY 1, 2019: (X as applicable)
RAPE (ART. 120)

SEXUAL ASSAULT (ART. 120)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

AGGRAVATED SEXUAL CONTACT (ART. 120)

UNKNOWN (NG ONLY)

ABUSIVE SEXUAL CONTACT (ART. 120)

PROSECUTED BY STATE LAW (NG ONLY)

e. IF VICTIM DUTY STATUS WAS NG AT THE TIME OF INCIDENT:
(2) VICTIM NATIONAL GUARD SERVICE AT TIME OF INCIDENT (X one)
(1) PAY GRADE AT TIME OF INCIDENT
TITLE 10

TITLE 32

(3) VICTIM NG TITLE 10 CATEGORY AT THE TIME OF INCIDENT (X one)
BASIC TRAINING

TECHNICAL/ADVANCED INDIVIDUAL TRAINING (AIT)

MOBILIZED OCONUS

MOBILIZED CONUS

ANNUAL TRAINING (AT)

ACTIVE DUTY ARMED SERVICES

ACTIVE GUARD AND RESERVE (AGR)

PROFESSIONAL MILITARY EDUCATION (PME)

ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)

(4) VICTIM NG TITLE 32 CATEGORY AT THE TIME OF INCIDENT (X one)
STATE ACTIVE DUTY (SAD)

INACTIVE DUTY TRAINING (IDT)

ANNUAL TRAINING (AT)

TECHNICIAN DUAL STATUS

TECHNICIAN NON-DUAL STATUS

RECRUIT SUSTAINMENT PROGRAM/STUDENT FLIGHT

PROFESSIONAL MILITARY EDUCATION (PME)

ROTC

ACTIVE GUARD AND RESERVE (AGR)

NOT IN DUTY STATUS

ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)

SECTION X – SEXUAL ASSAULT RELATED RETALIATION CASE INFORMATION
70. RETALIATION CONTROL NUMBER

71. ASSOCIATED DSAID CONTROL NUMBER

72. INVOLVES MULTIPLE DSAID CASES? (X one)
YES

73. SARC PRIMARY LOCATION (DSAID LOCATION CODE)

75. DSAID RETALIATION CASE STATUS (X one)
OPEN

CLOSED

DD FORM 2965, DRAFT 20211014

NO

74. DATE ALLEGATIONS OF RETALIATION WAS REPORTED (MM/DD/YYYY)

76. TYPE OF RETALIATION REPORTER (X one)
ADULT SEXUAL ASSAULT VICTIM

VICTIM'S FAMILY MEMBER

WITNESS

BYSTANDER (WHO INTERVENED)

SARC ON THIS CASE

RESPONDER

SAPR VA ON THIS CASE

OTHER PARTY

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

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CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
77. INDIVIDUAL/ORGANIZATION TO WHOM THE REPORT OF RETALIATION WAS MADE (X one)
ARMY IG

AIR FORCE IG

NAVY IG

AIR FORCE CHAIN OF COMMAND

USMC IG

COAST GUARD CHAIN OF COMMAND
ARMY LAW ENFORCEMENT

COAST GUARD IG

NATIONAL GUARD IG

NATIONAL GUARD CHAIN OF COMMAND
SPACE FORCE CHAIN OF COMMAND

AIR FORCE LAW ENFORCEMENT

COAST GUARD LAW ENFORCEMENT

SARC

ARMY CID

NAVY LAW ENFORCEMENT

SAPR VA

DOD IG

NAVY CHAIN OF COMMAND

ARMY CHAIN OF COMMAND

USMC CHAIN OF COMMAND

NCIS

AFOSI

CGIS

NG OCI

MARINE CORPS LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE

NON-DOD ENTITY

OTHER

78. OTHER INDIVIDUAL/ORGANIZATION TO WHOM THE REPORT OF RETALIATION WAS MADE
79. RETALIATION REPORTER NAME a. LAST

b. FIRST

c. MIDDLE

80. REPORTER IDENTIFICATION TYPE (X one)
DOD ID NUMBER

PASSPORT NUMBER

ALIEN REGISTRATION NUMBER

FOREIGN COUNTRY ID

UNKNOWN

ID NUMBER:

82. REPORTER GENDER (X one)

81. REPORTER DATE OF BIRTH (MM/DD/YYYY)

MALE

FEMALE

83. DATE THAT THE RETALIATION REPORTER WAS INFORMED OF THE TYPES OF INVESTIGATIVE ENTITIES, TO INCLUDE THE IG, AND THE
AVAILABILITY OF SVC/VLC (IF ELIGIBLE) (MM/DD/YYYY)
84. RETALIATION REPORTER AGREED TO HAVE THEIR CASE DISCUSSED AT CMG (X one)

YES

NO

85. PRIVACY ISSUES PREVENT SARC FROM DISCUSSING REPORTING ENTITIES WITH THE REPORTER (X one)

YES

NO

86. NARRATIVE OF THE RETALIATION ALLEGATION(S)

87. REPORTER TYPE (X one)
MILITARY

DOD CIVILIAN

DOD CONTRACTOR

OTHER GOVERNMENT CIVILIAN

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

UNKNOWN (SERVICE/DOD IG)

88. SERVICE AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

COAST GUARD

DOD

NOAA

PUBLIC HEALTH

N/A

89.a. DUTY STATUS (X one, if applicable)
ACTIVE DUTY

NATIONAL GUARD (NG)

RESERVE

b. IF REPORTER DUTY STATUS IS NG:
(1) REPORTER NATIONAL GUARD SERVICE (X one)

(2) REPORTER PAY PLAN (X one)

TITLE 10
TITLE 32

(5) REPORTER ASSIGNED LOCATION

GS

WG

NAF

SES

OTHER

UNKNOWN

(3) REPORTER PAY GRADE

(6) REPORTER ASSIGNED UNIT NAME

90. IS SUPPORT BEING PROVIDED TO THE REPORTER? (X one)

YES

(4) REPORTER GRADE

(7) REPORTER ASSIGNED UIC

NO

91. ACTIONS TAKEN TO SUPPORT REPORTER OF RETALIATION (X one)
BRIEFING/TRAINING FOR UNIT/INSTALLATION
UNFAVORABLE PERSONNEL ACTION, PUNISHMENT, OR ADMINISTRATIVE ACTION AGAINST THE RETALIATION REPORTER REVERSED
COMMAND IMPLEMENTED NEW POLICIES
TRANSFER OF RETALIATION REPORTER
MILITARY PROTECTIVE ORDER ISSUED OR CIVILIAN PROTECTIVE ORDER OBTAINED BY RETALIATION REPORTER
SAFETY PLAN UPDATED FOR RETALIATION REPORTER
COMMAND TOOK ACTION ON BEHALF OF THE RETALIATION REPORTER TO END THE NEGATIVE TREATMENT
COMMAND IS MONITORING THE SITUATION
COMMAND IS PROVIDING DIRECT SUPPORT TO THE REPORTER
ACTION PENDING
NO ACTION TAKEN
OTHER
UNKNOWN

DD FORM 2965, DRAFT 20211014

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

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CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
92. OTHER ACTIONS TAKEN TO SUPPORT REPORTER OF RETALIATION

93. REASON NO SUPPORT IS BEING PROVIDED (X one)
ALLEGATIONS UNSUBSTANTIATED BASED ON ADMINISTRATIVE INVESTIGATIONS

REPORTER LEFT SERVICE

ALLEGATIONS UNFOUNDED BASED ON CRIMINAL INVESTIGATIONS ONLY, PER DODI 5505.18

REPORTER DID NOT WANT ANY ACTION TAKEN

NO OFFICIAL COMPLAINT/COMPLAINT WITHDRAWN

REPORTER DIED/DESERTED

COMMAND DECLINED ACTION

OTHER

94. OTHER REASON NO SUPPORT IS BEING PROVIDED

96. INVESTIGATION CASE FILE OPENED (X one)

95. REPORTER SUPPORT CASE NOTES

YES

NO

97. REASON WHY NO INVESTIGATION OPENED (X one)
DID NOT MEET THE THRESHOLD FOR RETALIATION (I.E., REPRISAL ACTIONS, RESTRICTION, OSTRACISM, CRUELTY OR MALTREATMENT, OR CRIMINAL
ACT FOR A RETALIATORY PURPOSE)
REFERRED TO ANOTHER AGENCY TO INVESTIGATE (E.G., DOD IG)
REPORTER DIED

REPORTER DECLINED TO PARTICIPATE IN THE INVESTIGATION

REPORTER WITHDREW COMPLAINT

REPORTER IS ABSENT WITHOUT LEAVE

REPORTER SEPARATED FROM THE SERVICE

98. PROGRAM RESPONSIBLE FOR INVESTIGATING RETALIATION ALLEGATION(S) (X one)
ARMY IG

AIR FORCE IG

ARMY CHAIN OF COMMAND
USMC CHAIN OF COMMAND
AFOSI

CGIS

NAVY IG

USMC IG

AIR FORCE CHAIN OF COMMAND

COAST GUARD IG

COAST GUARD CHAIN OF COMMAND
NG OCI

MARINE CORPS LAW ENFORCEMENT

ARMY LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE (COAST GUARD)

ARMY CID

NCIS

NAVY LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE (ARMY)

MEO ADVISOR/REPRESENTATIVE (NAVY)

MEO ADVISOR/REPRESENTATIVE (MARINES)

MEO ADVISOR/REPRESENTATIVE (NATIONAL GUARD)

99. INVESTIGATIVE CASE NUMBER

DOD IG

NAVY CHAIN OF COMMAND

SPACE FORCE CHAIN OF COMMAND
AIR FORCE LAW ENFORCEMENT

COAST GUARD LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE (AIR FORCE)

NATIONAL GUARD IG

NATIONAL GUARD CHAIN OF COMMAND

NON-DOD ENTITY

100. DEFENSE CASE ACTIVITY TRACKING SYSTEM (IG) CASE NUMBER

101. DATE INVESTIGATIVE ACTIVITY OPENED (MM/DD/YYYY)

102. INVESTIGATIVE ACTIVITY COMPLETED? (X one)
YES

103. DATE INVESTIGATIVE ACTIVITY COMPLETED (MM/DD/YYYY)

NO

104. RESULTS OF THE INVESTIGATION PROVIDED TO RETALIATION
REPORTER? (X one)
YES, RESULTS PROVIDED TO THE REPORTER
NO, RESULTS NOT PROVIDED TO THE REPORTER

105. IF NO, REASON (RESULTS OF THE INVESTIGATION NOT PROVIDED TO RETALIATION REPORTER) (X one)
REPORTER SEPARATED FROM THE SERVICE

REPORTER IS ABSENT WITHOUT LEAVE

REPORTER DIED

OTHER

106. IF NO, OTHER REASON (WHY RESULTS OF THE INVESTIGATION NOT PROVIDED TO RETALIATION REPORTER)

107. IS RETALIATOR KNOWN? (X one)

YES

NO

108. RETALIATOR TYPE (X one)

109. RETALIATOR NAME
MILITARY

a. LAST

DOD CIVILIAN

DOD CONTRACTOR

OTHER GOVERNMENT CIVILIAN

b. FIRST
c. MIDDLE
110. IS DOD ID NUMBER AVAILABLE? (X one)
YES

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

UNKNOWN

111. IF YES, RETALIATOR DOD IDENTIFICATION NUMBER

NO

DD FORM 2965, DRAFT 20211014

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

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CUI (when filled in)
Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has been captured in the Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
112. RETALIATOR GENDER (X one)

MALE

FEMALE

113. RETALIATOR AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

114. RETALIATOR DUTY STATUS (X one)
ACTIVE DUTY

RESERVE

DOD

NOAA

PUBLIC HEALTH

N/A

115. RETALIATOR DUTY ASSIGNMENT (X one)

NATIONAL GUARD (NG)

116. RETALIATOR NATIONAL GUARD SERVICE (X one)
TITLE 10

COAST GUARD

RECRUITER

INSTRUCTOR

DRILL SERGEANT

DRILL INSTRUCTOR

N/A

117. RETALIATOR PAY GRADE AT TIME OF INCIDENT

TITLE 32

118. RELATIONSHIP BETWEEN ALLEGED RETALIATOR(S) AND RETALIATION REPORTER (X one)
ALLEGED RETALIATOR(S) IS A SUPERIOR IN THE CHAIN OF COMMAND OF THE REPORTER
ALLEGED RETALIATOR(S) IS A SUPERIOR NOT IN THE CHAIN OF COMMAND OF THE REPORTER
ALLEGED RETALIATOR(S) IS JUNIOR IN GRADE TO REPORTER (IN OR OUTSIDE OF THE CHAIN OF COMMAND)
ALLEGED RETALIATOR(S) IS A PEER, CO-WORKER, FRIEND, OR FAMILY MEMBER OF THE RETALIATION REPORTER
ALLEGED RETALIATOR(S) IS ASSOCIATED WITH ALLEGED PERPETRATOR OF SEXUAL ASSAULT
ALLEGED RETALIATOR(S) IS A SERVICE PROVIDER OR OTHER OFFICIAL INVOLVED IN THE REPORT
ALLEGED RETALIATOR(S) RELATIONSHIP IS UNKNOWN OR INVESTIGATION ONGOING
ALLEGED RETALIATOR(S) IS THE ALLEGED PERPETRATOR OF SEXUAL ASSAULT

119. RELATIONSHIP BETWEEN ALLEGED RETALIATOR AND ALLEGED PERPETRATOR OF SEXUAL ASSAULT (X one)
ALLEGED RETALIATOR(S) IS ALSO THE ALLEGED PERPETRATOR OF SEXUAL ASSAULT
ALLEGED RETALIATOR(S) IS A SUPERIOR OF THE ALLEGED PERPETRATOR (IN OR OUTSIDE CHAIN OF COMMAND)
ALLEGED RETALIATOR(S) IS JUNIOR IN GRADE TO THE ALLEGED PERPETRATOR (IN OR OUTSIDE CHAIN OF COMMAND)
ALLEGED RETALIATOR(S) IS A PEER, CO-WORKER, FRIEND, OR FAMILY MEMBER OF THE ALLEGED PERPETRATOR
ALLEGED RETALIATOR(S) AND ALLEGED PERPETRATOR HAVE NO DIRECT ASSOCIATION
ALLEGED RETALIATOR(S) RELATIONSHIP IS UNKNOWN/INVESTIGATION ONGOING
ALLEGED PERPETRATOR(S) RELATIONSHIP IS UNKNOWN/INVESTIGATION ONGOING

DD FORM 2965, DRAFT 20211014

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.

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