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

Per General Records Schedule (GRS) 4.3, Item 12, destroy after the information has been captured in the
Defense Sexual Assault Incident Database (DSAID).
OMB No. 0704-0482
OMB approval expires
xxx xx, xxxx

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 anypenalty 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, E-MAIL 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. 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): The information collected documents elements of the sexual assault response and/or reporting process and will be entered into
the DSAID to 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) and Installation SARC(s) use this 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 deidentified data is used to respond to mandated congressional reporting requirements. The applicable System of Records Notice is DHRA 06, DSAID found
at: http://dpcld.defense.gov/privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570559/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 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 or subjects should be captured. In the event that a SARC does not have immediate
access to the 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) 4.3, Item 12 and the rules for business use established in DoDI 6495.02, this form shall be destroyed as soon as the
information is input into DSAID. 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 in a
locked cabinet or drawer when not under the direct control of an individual with a need-to-know.
For select definitions of terminology used below, please see the DSAID User Manual.

NEEDS DD67
SECTION I - DSAID CASE INFORMATION

1. DSAID CONTROL NUMBER
RR UU -

2. TYPE OF REPORT (X one)

4. INDIVIDUAL WHO RECEIVED THIS
REPORT (X one)
SAPR VA
Other
SARC
Name:

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

3. SARC PRIMARY LOCATION (DSAID LOCATION)

5.a. DATE VICTIM SIGNED
FORM ELECTING TO
CONVERT FROM RR
TO RU (if applicable)

b. RU c. CONVERSION REASON (If known or available)

(MM/DD/YYYY)

6.a. DSAID CASE STATUS (X one)
Open
Closed
Open with Limited Information

b. EXPLANATION FOR OPEN WITH LIMITED INFORMATION STATUS (If applicable)
Victim refused/declined services
Victim opt-out of participating in investigative process
Local jurisdiction refused to provide victim information
Civilian victim with military subject
8. DATE OF REPORT TO DOD
7. RESTRICTED REPORT REASON
(MM/DD/YYYY)

9. RESTRICTED REPORT EXCEPTION APPLIED (X as applicable)
Disclosure is authorized by victim in writing.

Yes

No

If Yes, reason for exception:

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 or 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. FIRST
b. MIDDLE
c. LAST
11. ID TYPE (X one)
SSN
Passport Number
12. VA ASSIGNED (X one)
Yes
No

Alien Registration

If Yes, VA Name:

DD FORM 2965, DRAFT 20181119

Foreign Country ID

Unknown
If No, reason:

PREVIOUS EDITION IS OBSOLETE.

ID Number:

Page 1 of 6 Pages

Per General Records Schedule (GRS) 4.3, Item 12, destroy after the information has been captured in the
Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION II - VICTIM INFORMATION (At time of Report, unless otherwise indicated)
14. DATE VICTIM SIGNED DD FORM 2910

13. DATE VICTIM INFORMED OF OPTIONS (MM/DD/YYYY)

(MM/DD/YYYY)

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

Neighbor

Acquaintance

Employer

Stranger

Relationship Unknown

Love Interest/Dating

Extended Family Member

Supervisor/Command

Otherwise Known

Recruiter

Coworker

Employee

b. COMMAND NOTIFICATION If No, reason:
ACCOMPLISHED WITHIN
24 HOURS (X one)
Yes
No

16.a. COMMANDER NAME

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
Yes

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

20. GENDER (X one)

(MM/DD/YYYY)

21. RACE (X one)

No

22. ETHNICITY (X one)

Male

American Indian

Asian/Pacific Islander

Hispanic

Female

Black

Mixed

Unknown

White

Unknown

Not Hispanic

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

24. VICTIM TYPE (X one) (For adult dependents, select U.S. Civilian and complete Block 28.)
Military

DoD Civilian

Other Govt. Civilian

25. VICTIM AFFILIATION (X one)
Army

Navy

U.S. Civilian

Foreign Military

NEEDS DD67

Air Force

26. VICTIM STATUS

Marine Corps

National Guard (NG)

Coast Guard

DoD

NOAA

DoD Contractor

Public Health

N/A

b. VICTIM RECRUIT/TRAINING STATUS (X one)

a. IF MILITARY, VICTIM DUTY STATUS (X one)
Active Duty

Foreign National

Reserve

c.(1) If Victim Duty Status is NG, Type of National Guard Service (X one):

Yes

No

Title 10

Title 32

(2) Victim NG State Affiliation (X one)
50 States (Enter State:)

District of Columbia

(3) Victim NG Title 10 Category (X one)

National Guard

Puerto Rico

Guam

Virgin Islands

Active Duty Armed Services

Reservists

(4) Victim NG Title 32 Category (X one)
Active Guard and Reserve (AGR)

Traditional/M Day

Technician/Dual Status

Technician/Non-Dual 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

Other

e. IF VICTIM IS MILITARY/CIVILIAN, PAY GRADE

Unknown

g. VICTIM ASSIGNED UIC

i. IF GUARD OR RESERVE, WAS LINE OF DUTY (LOD) INITIATED? (X one)

h. VICTIM ASSIGNED UNIT NAME

Yes

Victim did not want LOD initiated

No information available from active duty SARC

Assault did not occur in duty status

Other

No

If No, X reason:

LOD not offered

27. IF NOT MILITARY, VICTIM DEPENDENT STATUS (X one)
Yes - Military Dependent

Yes - DoD Civilian (OCONUS) Dependent

28. WAS THE VICTIM IN THE MILITARY AT THE TIME OF THE ASSAULT? (X one)
29. IF MILITARY, IS VICTIM ADMINISTRATIVELY DISCHARGED WITHIN ONE YEAR OF
REPORTING? (X one)

DD FORM 2965, DRAFT 20181119

No
Yes

No
Yes

No

Case closed before 1 year mark
Page 2 of 6 Pages

Per General Records Schedule (GRS) 4.3, Item 12, destroy after the information has been captured in the
Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION III - VICTIM SAFETY (For multiple instances, reuse as needed)
30. VICTIM SAFETY ASSESSMENT COMPLETED? (X and complete as applicable)
a. IF YES, WAS A VICTIM SAFETY CONCERN IDENTIFIED? (X one)
Yes

Yes

No

No

b. IF YES, VICTIM SAFETY CONCERN NOTE(S)

c. IF A VICTIM SAFETY ASSESSMENT WAS NOT COMPLETED, WHAT WAS THE REASON?

d. VWAP (DD Form 2701) PROVIDED
(X one)

Yes

No

31. VICTIM INFORMED OF RIGHT TO REQUEST EXPEDITED TRANSFER? (X one; for military victims only)
Yes
No
a. EFFECTIVE DATE OF CPO (MM/DD/YYYY)
Yes If Yes:
32. CIVILIAN PROTECTIVE ORDER (CPO) REQUESTED? (X and
complete as applicable)

No
Yes
33. MILITARY PROTECTIVE ORDER (MPO) REQUESTED? (X and complete as applicable)
a. MPO REQUEST DATE
b. MPO ISSUED (X)
c. MPO ISSUE DATE
d. MPO VIOLATED (X)
(MM/DD/YYYY)

(MM/DD/YYYY)

Yes
No

34. VICTIM EXPEDITED TRANSFER (If applicable; for military victims only)
a. DATE VICTIM REQUESTED EXPEDITED TRANSFER
(MM/DD/YYYY)

c. COMMAND DECISION FOR EXPEDITED TRANSFER (X one)
Approve
Disapprove
e. VICTIM REQUESTED REVIEW FOR
EXPEDITED TRANSFER (X one)
Yes

Approve

Victim
Both

Yes
No

Subject

b. VICTIM EXPEDITED TRANSFER REQUESTED TYPE (X one)
Local - Unit/Duty Transfer
PCS - Installation Transfer
d. DATE OF COMMAND DECISION FOR EXPEDITED TRANSFER (MM/DD/YYYY)

f. SENIOR LEVEL DECISION FOR EXPEDITED
TRANSFER (X one)

No

No If Yes:
e. IF YES, BY WHOM? (X)

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

Disapprove

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

Military

Civilian

NEEDS DD67

Mental Health
Medical
Legal
Victim Advocate/Uniformed Victim Advocate
Rape Crisis Center

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

Chaplain/Spiritual Support
DoD Safe Helpline
Other (Specify)

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

36. REFERRAL RESOURCE TYPE (X and complete as applicable)
a. TYPE OF REFERRAL SUPPORT (X)
Medical
Mental Health
Legal
Victim Advocate/Uniformed Victim Advocate

Military

Civilian
b. DATE OF REFERRAL (MM/DD/YYYY)

Chaplain/Spiritual Support
DoD Safe Helpline
Other (Specify)

Rape Crisis Center
c. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

37. REFERRAL RESOURCE TYPE (X and complete as applicable)
a. TYPE OF REFERRAL SUPPORT (X)
Medical
Mental Health
Legal
Victim Advocate/Uniformed Victim Advocate

Military

Civilian
b. DATE OF REFERRAL (MM/DD/YYYY)

Chaplain/Spiritual Support
DoD Safe Helpline
Other (Specify)

Rape Crisis Center
c. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

38. REFERRAL RESOURCE TYPE (X and complete as applicable)
a. TYPE OF REFERRAL SUPPORT (X)
Medical
Mental Health
Legal
Victim Advocate/Uniformed Victim Advocate

Military

Civilian
b. DATE OF REFERRAL (MM/DD/YYYY)

Chaplain/Spiritual Support
DoD Safe Helpline

Rape Crisis Center
Other (Specify)
c. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

DD FORM 2965, DRAFT 20181119

Page 3 of 6 Pages

Per General Records Schedule (GRS) 4.3, Item 12, destroy after the information has been captured in the
Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION V - FORENSIC EXAM
Yes

39. WAS FORENSIC EXAM OFFERED? (X one)

No

If No, reason:

40. WAS FORENSIC EXAM COMPLETED? (X and complete as applicable)
(2) Date of Exam (MM/DD/YYYY)

a. IF YES: (1) Location of Forensic Exam:
On Installation

Off Installation
(3) Storage Location of SAFE Kit

Yes

No

b. IF NO, WAS IT BECAUSE SAFE KIT AND/OR OTHER
NEEDED SUPPLIES NOT AVAILABLE?
Yes

No

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

Yes

42. VICTIM NOTIFIED SAFE KIT DUE TO EXPIRE WITHIN 60 DAYS? (For Restricted Reports only. X and complete as applicable)
a. IF YES, DATE VICTIM NOTIFIED SAFE KIT WAS DUE
TO EXPIRE (MM/DD/YYYY)

b . IF NO, REASON (X)
Victim has died

Victim has ETS/retired

No

Unable to contact victim

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

Yes

No

b. INITIAL INVESTIGATIVE AGENCY LOCATION

NEEDS DD67

*Refer to the DSAID Support page for current Investigative Case Number formats.
c. IF NO, PROVIDE A REASON (X and complete as applicable)
Incident occurred prior to victim's military service

Alleged perpetrator not subject to UCMJ

Incident beyond statute of limitations

NG/JA/OCI

Civilian Law Enforcement

Other (Specify)

44. AGENCY CONDUCTING INVESTIGATION (X one)
NCIS

AFOSI

Army CID

45. DATE INVESTIGATIVE ACTIVITY OPENED

CGIS

46. INVESTIGATIVE ACTIVITY COMPLETED (X and complete as applicable)

(MM/DD/YYYY)

Yes

IF YES, DATE INVESTIGATIVE ACTIVITY COMPLETED (MM/DD/YYYY)

No

SECTION VII - INVESTIGATIVE AGENCY CASE TRANSFER (If applicable)
47. INVESTIGATIVE AGENCY CASE TRANSFERRED (X one)
Across Services

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

Within Services

To Non-Military Jurisdiction
49. INVESTIGATIVE AGENCY CASE
TRANSFER DATE (MM/DD/YYYY)

50. AGENCY CONDUCTING INVESTIGATION (X one)
NCIS

AFOSI

Army CID

NG/JA/OCI

CGIS

Civilian Law Enforcement

51. GAINING INVESTIGATIVE AGENCY LOCATION

DD FORM 2965, DRAFT 20181119

Page 4 of 6 Pages

Per General Records Schedule (GRS) 4.3, Item 12, destroy after the information has been captured in the
Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION VIII - SUBJECT INFORMATION (For multiple subjects, reuse as needed.)
52. RESTRICTED REPORT: SUBJECT TYPE (X one)
Military - Cadet/Midshipman/Prep School Student
Other Govt. Civilian
U.S. Civilian
UNRESTRICTED REPORT:
53. SUBJECT NAME: a. LAST

b. FIRST

54. ID TYPE (X one)
SSN
Passport Number
Foreign Country ID
Unknown

c. MIDDLE
55. DATE OF BIRTH 56. AGE AT TIME 57. GENDER (X one)
(MM/DD/YYYY)
OF INCIDENT
Male
Female

Alien Registration
ID Number:

Unknown

58. RACE (X one)
American Indian
White

Asian/Pacific Islander
Mixed

Black
Unknown

61. SUBJECT TYPE (X one)
Military
Foreign National

DoD Civilian
Foreign Military

Other Government Civilian
DoD Contractor

62. SERVICE AFFILIATION (X one)
Army
Navy
Air Force
63. DUTY STATUS (X one, if applicable)

DoD Civilian
Unknown

Military - Non Cadet/Midshipman/Prep School Student
Foreign National
Foreign Military
DoD Contractor

Marine Corps

59. ETHNICITY (X one)
Hispanic
Not Hispanic
Unknown

Coast Guard

Active Duty
National Guard (NG)
Reserve
a. 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:)

60. DEPENDENT
STATUS (X one)
Yes

No

U.S. Civilian
Unknown
DoD

NOAA

Public Health

Unknown

Unknown

District of Columbia
Puerto Rico
Guam
Virgin Islands
Active Guard and Reserve (AGR)
(3) Subject NG Title 10 Category (X one)
Active Duty Operational Support (ADOS)
Basic Training
Technical/Advanced Individual Training (AIT)
Annual Training (AT)
Active Duty Armed Services
Mobilized OCONUS
Mobilized CONUS
Professional Military Education (PME)
Reservists
Title 32

NEEDS DD67

Active Guard and Reserve (AGR)
Professional Military Education (PME)
ROTC
State Active Duty (SAD)
Not in Duty Status
(5) NG Subject Recruit/Training Status (X one)
(4) Subject NG Title 32 Category (X one)
Active Duty Operational Support (ADOS)

Annual Training (AT)
Inactive Duty for Training (IDT)
Recruit Sustainment Program/Student Flight

NG Pre-Accession Recruit Sustainment Program (RSP)
Pre-Recruit General Education Development (GED) Program
b. IF SUBJECT IS MILITARY/CIVILIAN, PAY GRADE
c. SUBJECT DUTY ASSIGNMENT (X one)
Recruiter

Instructor

Drill Sergeant

d. IF SUBJECT IS A DOD CIVILIAN/OTHER GOVERNMENT CIVILIAN: PAY PLAN (X one)
Unknown
GS
WG
NAF
SES
Other
f. SUBJECT ASSIGNED UNIT NAME
e. SUBJECT ASSIGNED LOCATION

N/A

Drill Instructor

N/A

g. SUBJECT ASSIGNED UIC

SECTION IX - SUBJECT DISPOSITION (For multiple subjects, reuse as needed.)
64. PRE-TRIAL CONFINEMENT OF SUBJECT (X one)

a. IF YES, DATE OF PRE-TRIAL CONFINEMENT OF SUBJECT
(MM/DD/YYYY)
Yes
No
Unknown (NG only)
65. CAN DOD CONSIDER ACTION AGAINST
a. IF YES, DOD ACTION DECISION DATE
b. IF YES, IS REPORT SUBSTANTIATED? (X one)
SUBJECT? (X one)
(MM/DD/YYYY)
Yes
No
Yes
No
66. IF REPORT IS SUBSTANTIATED, IDENTIFY COMMAND ACTION (X one)
a. COMMAND ACTION DATE
Courts-martial charge preferred
CM charge preferred for non-SA offense
(MM/DD/YYYY)
Non-judicial punishment
Administrative discharge
Other adverse administrative action
Cadet disciplinary system action
Non-judicial punishment for non-SA offense
Administrative discharge for non-SA offense
Other adverse administrative actions for non-SA offense
67. IF REPORT IS UNSUBSTANTIATED, IDENTIFY REASON COMMAND ACTION PRECLUDED OR
68. IF DOD CANNOT TAKE ACTION
AGAINST SUBJECT, DOD ACTION
DECLINED (X one)
DECISION DATE (MM/DD/YYYY)
Victim declined to participate in Military Justice action
Insufficient evidence of any offense

Victim died before completion of Military Justice action
Unfounded by Command
Statute of limitations expired
69. WAS THE REPORT AGAINST SUBJECT
70. IF NOT UNFOUNDED, WHAT IS THE REASON THE SUBJECT IS OUTSIDE OF DOD
UNFOUNDED BY INVESTIGATIVE
PROSECUTIVE AUTHORITY? (X one)
AGENCY? (X one)
Offender is unknown
Subject is a civilian or foreign national
A civilian/foreign authority is Prosecuting Service Member
Subject died or deserted
Yes
No
Page 5 of 6 Pages
DD FORM 2965, DRAFT 20181119

Per General Records Schedule (GRS) 4.3, Item 12, destroy after the information has been captured in the
Defense Sexual Assault Incident Database (DSAID).

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION X - INCIDENT DETAIL
71. FOR RESTRICTED REPORT, IS DATE OF INCIDENT KNOWN (X and complete as applicable)
a. IF YES, DATE OF INCIDENT (MM/DD/YYYY)

Yes

No

b. IS DATE AN ESTIMATE? (X one)
Yes

No

72. FOR UNRESTRICTED REPORT:
a. DATE OF INCIDENT (MM/DD/YYYY)

b. IS DATE AN ESTIMATE? (X one)
Yes

No

73. INCIDENT TIME OF DAY

74. INCIDENT LOCATION (X one)
On Military Installation/Ship (other than Academy grounds)

On Academy grounds

Off Military Installation/Ship/Academy grounds
a. TYPE OF LOCATION (For example, private vehicle or hotel)

Unidentified

75. FOR VICTIM AND/OR SUBJECT: (X as applicable)
Yes

a. WAS ALCOHOL INVOLVED?
76. WEAPONS USED? (X as applicable)

No

Unknown

Yes

b. WERE DRUGS INVOLVED?

No

Yes

No

Unknown

Unknown

77. TYPE(S) OF OFFENSE INVESTIGATED
a. FOR INCIDENTS OCCURRED PRIOR TO OCTOBER 1, 2007: (X as applicable)
Rape (Art. 120)

Indecent Assault (Art. 134)
Non-Consensual Sodomy (Art. 125)
Prosecuted by State Law (NG only)

Attempts to Commit Offenses (Art. 80)

NEEDS DD67

Unknown (NG only)

b. FOR INCIDENTS OCCURRED AFTER OCTOBER 1, 2007 AND BEFORE JUNE 28, 2012: (X as applicable)
Rape (Art. 120)
Abusive Sexual Contact (Art. 120)

Attempts to Commit Offenses (Art. 80)

Aggravated Sexual Assault (Art. 120)
Wrongful Sexual Contact (Art. 120)
Unknown (NG only)

Aggravated Sexual Contact (Art. 120)
Non-Consensual Sodomy (Art. 125)
Prosecuted by State Law (NG only)

c. FOR INCIDENTS OCCURRED ON OR AFTER JUNE 28, 2012: (X as applicable)
Rape (Art. 120)

Aggravated Sexual Contact (Art. 120)
Sexual Assault (Art. 120)
Attempts to Commit Offenses (Art. 80)
Unknown (NG only)
Non-Consensual Sodomy (Art. 125)

Abusive Sexual Contact (Art. 120)
Prosecuted by State Law (NG only)

d. IF VICTIM DUTY STATUS WAS NG AT THE TIME OF INCIDENT:
(1) Pay Grade at the Time of Incident

(2) Victim National Guard Service at the Time of Incident (X one)
Title 10

Title 32

(3) Victim NG Title 10 Category at the Time of Incident (X one)
Basic Training
Technical/Advanced Individual Training (AIT)
Annual Training (AT)
Active Duty Armed Services
Professional Military Education (PME)

Mobilized OCONUS
Mobilized CONUS
Active Guard and Reserve (AGR)
Active Duty Operational Support (ADOS)

(4) Victim NG Title 32 Category at the Time of Incident (X one)
State Active Duty (SAD)
Technician Non-Dual Status
ROTC

DD FORM 2965, DRAFT

Inactive Duty Training (IDT)
Annual Training (AT)
Not in Duty Status
Technician Dual Status
Recruit Sustainment Program/Student Flight
Professional Military Education (PME)
Active Duty Operational Support (ADOS)
Active Guard and Reserve (AGR)
Page 6 of 6 Pages
20181119