DD Form 2967 Domestic Abuse Victim Reporting Option Statement

CUI (when filled in)
OMB No. 0704-DARS
Exp. TBD

DOMESTIC ABUSE VICTIM REPORTING OPTION STATEMENT
(Please read Privacy Act Statement before completing this form.)

The public reporting burden for this collection of information, 0704-DARS, is estimated to average 1.25 hours 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 the burden estimate or burden reduction suggestions 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.
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;
DoDI Instruction (DoDI) 6400.01, Family Advocacy Program (FAP); DoDI 6400.06, DoD Coordinated Community Response to Domestic Abuse Involving DoD Military and Certain Affiliated Personnel; Department of
the Air Force Instruction 40-301, Family Advocacy Program; Army Regulation 608-18, The Family Advocacy Program; Secretary of the Navy Instruction 1752.3A, Family Advocacy Program (FAP); Marine Corps
Order 1754.11, Marine Corps Family Advocacy and General Counseling Program; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): Information on this form documents your decision of whether to file a restricted or unrestricted report of domestic abuse.
ROUTINE USE(S): Applicable Routine Use(s) are: To departments and agencies of the Executive Branch of government in performance of their official duties relating to coordination of family advocacy programs,
medical care, and research concerning family maltreatment and neglect. To federal, state or local government agencies when it is deemed appropriated to utilize civilian resources in the counseling and treatment of
individuals or families involved in abuse or neglect or when it is deemed appropriate or necessary to refer a case to civilian authorities for civil or criminal law enforcement.
Additional Routine uses are listed in the following applicable system of records notices:
Air Force: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569871/f044-af-sg-q/
Army: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570082/a0608-18-dasg/
Navy: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570332/n01752-1/
DISCLOSURE: Voluntary, however, if certain information is not provided it may impede the ability for Domestic Abuse Victim Advocate (DAVA) to offer the full range of care and support established by the Family
Advocacy Program.

1. REPORTING PROCESS AND OPTIONS DISCUSSED WITH THE DOMESTIC ABUSE VICTIM ADVOCATE or THE FAP CLINICAL PROVIDER
I,

had the opportunity to talk with a:
Domestic Abuse Victim Advocate (DAVA),
DAVA supervisor,
FAP clinical provider,
or Healthcare Provider (HCP) (Specify)
, before selecting a reporting option.
2. I have been provided the following information on the reporting options and initial below to indicate my understanding of the terms of that
selection.
2a. UNRESTRICTED REPORTING - REPORTING A CRIME WHICH IS INVESTIGATED (Restricted reporting is limited to adult domestic abuse victims who are
eligible to receive medical care from the DoD per Section 5.3 of DoDI 6400.06.)
INITIALS

I understand that law enforcement and command will be notified that I am a victim of domestic abuse and an investigation will be started. I
understand that I can receive medical treatment, advocacy services, and counseling. The full range of victim protection actions may be
available to me, such as being separated from the alleged abuser, obtaining a military protection order and/or obtaining a civil protection
order.

2b. RESTRICTED REPORTING - CONFIDENTIALLY REPORTING A CRIME WHICH IS NOT INVESTIGATED
INITIALS

a. I understand that there are exceptions to "Restricted Reporting" (listed below). If an exception applies, limited or full details of the abuse
report may be disclosed to satisfy the exception.

INITIALS

b. I understand that I can confidentially receive medical treatment, advocacy services, counseling, and Special Victim's Counsel or Victims
Legal Counsel (SVC/VLC), but law enforcement and command will NOT be notified. My report will NOT trigger an investigation; therefore, no
action will be taken against the abuser as the result of my report.

INITIALS

c. I understand that all state laws, local laws or international agreements that may limit some or all of DoD's restricted reporting protections
, medical authorities must report the domestic abuse
have been explained to me. In
to

INITIALS

d. I understand that the DAVA, FAP clinical provider, or their supervisor will provide information that does not reveal the identity, nor that of
the alleged abuser, to the command. The purpose of this information is required for public safety, providing command information on the
types of domestic abuse in their command and to enhance command's ability to provide a safe environment.

INITIALS

e. I understand that by choosing "Restricted Reporting," the full range of victim protection actions may not be available, such as being
separated from, or obtaining a military protection order against, the alleged abuser.

INITIALS

f. I understand that if I talk about my abuse to anyone other than designees under the "Restricted Reporting" option (DAVA, DAVA
supervisor, FAP clinical provider, or Health Care Provider), it may be reported to the command and law enforcement, which could lead to an
investigation. I understand that I may also confide in a Sexual Assault Response Coordinator, sexual assault victim advocate, Military One
Source Provider, Military Family Life Counselor, Prevention personnel under the Family Advocacy Program, and/or the Chaplain and still
preserve the option of a restricted report.
g. I understand that I may change my mind and later decide to report this abuse incident as an "Unrestricted Report," and law enforcement
and the command will be notified. I also understand that delayed reporting may limit the ability to prosecute the alleged abuser. I understand
that if the case goes to court, my DAVA, FAP clinical provider, and others providing care may be called to testify about any information I
shared with them.

INITIALS

NEEDS DD67

3. I have been advised of the following reasons as Exceptions on Restricted Reporting, including: (Include all from the list)
EXCEPTIONS TO RESTRICTED REPORTING
In cases in which a victim elects restricted reporting, the prohibition on disclosing covered communications to the following persons or entities will be suspended when
disclosure would be for the following reasons:
1. Named individuals where disclosure is authorized by the victim in writing.
2. Command or law enforcement when necessary to prevent or lessen a serious and imminent threat to the health or safety of the victim or another person, including
dependent children.
3. FAP personnel or HCP when reporting information of the incident to command and/or law enforcement is necessary to prevent or lessen a serious and imminent threat
to the health or safety of the victim or another person, including dependent children.
4. FAP and any other agencies authorized by law to receive reports of child abuse or neglect when, as a result of the victim's disclosure, the DAVA, FAP clinical provider, or
HCP has a reasonable belief that child abuse has also occurred. However, disclosure will be limited only to information related to the child abuse/neglect.
5. Disability Retirement Boards and officials when disclosure by an HCP is required for fitness for duty for disability retirement determinations. Disclosure will be limited to
only that information which is necessary to process the disability retirement determination.
6. Supervisors of the DAVA, FAP clinical provider, or HCP when disclosure is required for the supervision of direct victim treatment or services.
7. Military or civilian courts of competent jurisdiction when a military, Federal or State judge issues a subpoena for the covered communications to be presented to the
court, to officials or entities when the judge orders such disclosure; or to other officials or entities when required by Federal or State statute or applicable U.S. international
agreement.
8. Restricted Reporting DOES NOT apply to cases of child abuse or neglect. ALL child abuse is reportable and when child abuse occurs as part of a domestic abuse
incident, restricted reporting may be compromised.

DD FORM 2967, DRAFT 20230419
PREVIOUS EDITION IS OBSOLETE.

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Controlled by: OUSD(P&R)
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Distribution/Dissemination Control: FEDCON
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4. I have been informed about services that may be available to me, to include:
INITIALS
a. Availability of SVC/VLC who can provide me with legal advocacy and representation, if applicable and eligible.
INITIALS

b. (For Active Duty (AD) Expedited Transfer) Reassignment/relocation options, through a separate administrative/command process, may
allow me to transfer/relocate for the purpose of safety and recovery/healing. (Expedited Transfer is NOT available for restricted reports.)

INITIALS

c. (For AD Personnel) If I experience retaliation from supervisors or peers within my command after reporting domestic abuse, I can report to
my DAVA or FAP clinical provider. If I filed an unrestricted report, I can also report to SVC/VLCs, my commander/leadership, law
enforcement, Victim Witness Assistance Program, EO personnel, or the Inspector General.

INITIALS

d. (For Civilian Victims) If I experience retaliation from supervisors or peers of my active duty abuser after reporting domestic abuse, I can
report to my DAVA or FAP clinical provider. If I filed an unrestricted report, I can also report to the Service member's command/leadership,
SVC/VLCs, law enforcement, Victim Witness Assistance Program, EO personnel or the Inspector General.

INITIALS

e. (For AD Personnel) I have been advised that I may be eligible for Department of Veterans Affairs services and information is available at
https://www.mentalhealth.va.gov/msthome/index.asp
f. If reporting Sexual Abuse, I have been informed about:

INITIALS

(1) Availability of a Sexual Assault Forensic Examination (SAFE), if appropriate, and that both medical and personal property (clothing) may
be collected for evidence. I may request the return of my property at any time; however, that may compromise the processing of evidence if I
convert to an unrestricted report.

INITIALS

(2) Evidence collected from my SAFE will be stored for 10 years from the date it is collected or when the DD Form 2967 is signed, if the
SAFE was conducted at a Military Treatment Facility. Evidence collected by a civilian medical facility will be stored per established
memorandum of understanding with DoD or per state or local laws. Personal property may be returned earlier than 10 years. See DoDI
5505.18 (January 2019).

INITIALS

(3) The CATCH program, which allows me to voluntarily provide information about the alleged abuser, who may be a serial sex abuser,
without identifying myself, if I elect a restricted report.

I elect to participate in CATCH

I desire to be updated on CATCH if a match is found (X one):
If yes, enter email

Yes

I elect NOT to participate in CATCH

No
or phone number:

Contact information will be transferred to Service FAP Headquarters so that I may be contacted if a match is found within 10 years.
INITIALS

(4) (For AD Personnel) Emotional support and documentation, per Service policy, of reported harassment and/or retaliation as a result of
reporting sexual abuse.

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5. CHOOSE A REPORTING OPTION (Initial your selection)

There may be implications for sharing an incident of abuse and not making an election. Making an election gives me some control over who is made aware of my
report of abuse. FAP staff take all measures to respect my election, but must first prioritize my safety.
INITIALS

INITIALS

a. Unrestricted Report. I elect Unrestricted Reporting and have decided to report that I am a victim of domestic abuse to command, law
enforcement, or other military authorities for investigation of this crime.
b. Restricted Report. I elect Restricted Reporting and have decided to confidentially report that I am a victim of domestic abuse. The
command will NOT be provided with information about my identity. 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 abuser
accountable.

5c. PRINTED NAME OF VICTIM

5d. SIGNATURE OF VICTIM

5e. DATE (YYYYMMDD)

6a. PRINTED NAME OF PROVIDER

6b. SIGNATURE OF PROVIDER

6c. DATE (YYYYMMDD)

6d. PRINTED NAME OF SUPERVISOR (If Required)

6e. SIGNATURE OF SUPERVISOR (If Required)

6f. DATE (YYYYMMDD)

7. RESTRICTED REPORT CASE NUMBER (If applicable)
8. I have reconsidered my previous election of a"Restricted Report" and I would like to make an "Unrestricted Report" of domestic abuse to
command and law enforcement in order to initiate a possible investigation.
8a. PRINTED NAME OF VICTIM

8b. SIGNATURE OF VICTIM

8c. DATE (YYYYMMDD)

8d. PRINTED NAME OF PROVIDER

8e. SIGNATURE OF PROVIDER

8f. DATE (YYYYMMDD)

8g. PRINTED NAME OF SUPERVISOR (If Required)

8h. SIGNATURE OF SUPERVISOR (If Required)

8i. DATE (YYYYMMDD)

DD FORM 2967, DRAFT 20230419
PREVIOUS EDITION IS OBSOLETE.

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DO NOT COMPLETE THIS PAGE UNLESS A REPORT OF RETALIATION IS APPLICABLE
1. Retaliation Reporting Process Discussed with DAVA, DAVA Supervisor, or FAP Clinical Provider:
I, (Full Name)

and DoD Identification Number (for personnel with Common Access Cards only)

met with a DAVA or a FAP clinical provider to discuss retaliation experienced by me.
INITIALS
(a) The FAP clinical provider or DAVA discussed available resources with me to report instances of retaliation, reprisal, ostracism, or maltreatment, and, if I am interested
and eligible, the process to request an Expedited Transfer.
(b) The FAP clinical provider/DAVA has informed me of available support services, to include mental health providers, and chaplain resources.
(c) The FAP clinical provider or DAVA explained that I can consult with a Special Victims' Counsel (SVC), Victims' Legal Counsel (VLC), or a legal assistance attorney, if I
am eligible for one, before deciding to file this report of retaliation. I understand that the SVC/VLC may discuss the legal definition of retaliation, available reporting
options, and the investigative and military justice processes involved.
(d) The FAP clinical provider or DAVA explained that reporting retaliation to FAP does not constitute an official report for purposes of an investigation related to the
retaliation being experienced. I understand that I must contact the DoD IG DIRECTLY if I want to file a Retaliation complaint with the IG.
Information for the “IG Hotline – Whistleblower Reprisal Complaints,” can be found at: https://www.dodig.mil/Components/Administrative-Investigations/
WhistleblowerReprisal-Investigations/Whistleblower-Reprisal
(e) If I am a Service member and if I report retaliation because I am being processed for an administrative separation within one year of the final disposition of the victim’s
sexual assault case, the FAP clinical provider or DAVA explained that I may request that the appropriate General or Flag Officer (G/FO) in my chain of command review
the separation. [In accordance with 24 Jan 2018, P&R Memo, “Execution of the Department of Defense Retaliation Prevention and Response Strategy Implementation
Plan-Sexual Assault"; hereafter 24 January 2018 P&R Retaliation Memo].
(f) If I am a Service member and I believe that there were impacts to my military career because I reported retaliation, the FAP clinical provider or DAVA explained that I
have the right to discuss those career impacts with a G/FO. [In accordance with 24 January 2018 P&R Retaliation Memo].
2. DESIGNATION OF PERSON REPORTING RETALIATION: I am the (please indicate below)
INITIALS
(1) Adult Sexual Assault Victim, who has previously made an unrestricted report of sexual abuse
(2) Adult Sexual Assault Victim’s adult family member, please specify the relationship to the sexual abuse victim (i.e., spouse, son, daughter, etc.):

(3) Witness
(4) Bystander (who intervened)

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(5) FAP clinical provider on this case
(6) DAVA on this case

(7) Responder, please specify the type of responder:

(8) Other party to the incident, please specify (i.e., friend, co-worker, etc.):

3. SIGNATURE OF RETALIATION REPORTER

DATE (YYYYMMDD)

4. SIGNATURE OF FAP CLINICAL PROVIDER OR DAVA AND PRINT NAME

DATE (YYYYMMDD)

5. FAP INSTALLATION AND CONTACT INFORMATION:

6. NOTES (This section should be used for any notes or information that is applicable to the retaliation report.)

DD FORM 2967, DRAFT 20230419
PREVIOUS EDITION IS OBSOLETE.

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INSTRUCTIONS
1. REPORTING PROCESS AND OPTIONS DISCUSSED WITH THE
DOMESTIC ABUSE VICTIM ADVOCATE or THE FAP CLINICAL
PROVIDER
In this section, the reporter (or identified victim making their election)
will complete their name (first and last name), and identify the party
or parties that were present to explain the available reporting options.
In rare circumstances, a Healthcare Provider may be present for the
discussion of reporting options information with the DAVA, DAVA
supervisor, or FAP clinical provider (section 5).
2a. UNRESTRICTED REPORTING - REPORTING A CRIME WHICH
IS INVESTIGATED
If the victim is electing to make an unrestricted report or does not
have the restricted reporting option available due to the applicability
of an exception, the individual will acknowledge understanding that
law enforcement and command will be notified. Furthermore, the
individual may be eligible to receive treatment, advocacy, and
counseling services. The reporting preference form is not required to
be completed in the event (1) the report of abuse was received from
an official military or civilian agency which makes the incident
ineligible for a restricted report, or (2) the victim is not eligible for a
restricted report, as restricted reporting is limited to adult domestic
abuse victims who are eligible to receive medical care from the DoD.
When a report of child abuse is made as part of a domestic abuse
allegation, the child abuse must be reported to the command, law
enforcement, and child welfare services by FAP. The full range of
victim protection actions may be available. (Section 5.2 of DoDI
6400.06)
2b. RESTRICTED REPORTING - CONFIDENTIALLY REPORTING
A CRIME WHICH IS NOT INVESTIGATED
When the victim is eligible for, and does elect to make a restricted
report, the individual will acknowledge each of the boxes (a through
g). Restricted reporting is limited to adult domestic abuse victims who
are eligible to receive medical care from the DoD. (Section 5.3 of
DoDI 6400.06)

4. The victim will acknowledge being informed of available services
that they are eligible for based on their present status (military or
civilian member), and applicability of this section under a through e.
4f. When the victim is making a sexual abuse report, they will be
informed about the processes and procedures outlined in (1) through
(5).
5. The victim will select their desired reporting option election upon
reviewing this form in its entirety with the DAVA, DAVA supervisor, or
FAP clinical provider. In making an election, it will be reiterated that
the victim may elect to go from a restricted report to an unrestricted
report at a later time; however, an unrestricted report may not be
converted to a restricted report at a later date/time. In the event that
the victim did not have the option to make an election due to an
exception or eligibility restriction, the DAVA, DAVA supervisor, or
FAP clinical provider will thoroughly explain this to the victim.
5a. and 5d. The victim will complete their election by initialing one of
the boxes (either restricted or unrestricted).
5c. through 5e. Completed by the victim with the noted information.
6a. through 6c. Completed by the FAP advocate or provider
completing the form with the victim.
6d. through 6f. Completed by the reviewing supervisor after the form
has been completed in its entirety.
7. RESTRICTED REPORT CASE NUMBER. The RR case number is
generated in accordance with DODI 6400.06 and the applicable
Service policy.

NEEDS DD67

2b.a. The victim will acknowledge understanding that there are
exceptions to "Restricted Reporting", as outlined in the
EXCEPTIONS TO RESTRICTED REPORTING. If an exception
applies, limited or full details of the abuse reported may be disclosed
to satisfy the exception. (Section 5.3 of DoDI 6400.06)

2b.b. The victim will acknowledge understanding that they may
confidentially receive medical treatment, advocacy services,
counseling, and Special Victims Counsel or Victims Legal Counsel
(SVC/VLC), and law enforcement and command will NOT be notified
to open an official investigation.
2b.c. The victim will acknowledge receipt of information pertaining to
all applicable laws in the state, country, or territory where they are
making the restricted report. In instances where an exception would
apply, the state will be noted, and the information regarding medical
authorities being required to report the domestic abuse incident will
be filled in this area.

2b.d. The victim will acknowledge understanding that the DAVA,
DAVA supervisor, or FAP clinical provider will provide information
that does not reveal their identity, nor that of the alleged abuser, to
the responsible senior commander. The purpose of making such a
report is for purposes of public safety, providing command
information on the types of domestic abuse in their command, and to
enhance the command's ability to provide a safe environment.
2b.e. The victim will acknowledge understanding that by electing to
make a restricted report, the full range of victim protection actions will
not be available to separate them from the alleged abuser.
2b.f. The victim will acknowledge that they are aware that if they
confide in any person other than the personnel noted, then the
preservation of their option to make a restricted report may be
compromised. (Section 5.3 of DoDI 6400.06)
2b.g. The victim will acknowledge awareness that they may change
their mind and later decide to report the abuse incident as an
"Unrestricted Report," and law enforcement and the command will be
notified. The victim should be advised and a discussion had about
the fact that the report being converted may impact investigation and
prosecution of the alleged abuser. If the case does go to court, the
DAVA, FAP clinical provider, and others that are providing care may
be called to testify in accordance with applicable state or local laws,
the Uniformed Code of Military Justice or other statutes and policies.
3. This section provides information associated with the Exceptions
on Restricted Reporting. The victim and advocate or provider
reviewing this form will allot time for discussion of each of these
exceptions in detail. (Section 5.3.c of DoDI 6400.06)

DD FORM 2967, DRAFT 20230419
PREVIOUS EDITION IS OBSOLETE.

8. This section will only be completed if and when a victim has
reconsidered their previous election of a "Restricted Report" and
would like to make an "Unrestricted Report" of domestic abuse to
command and law enforcement in order to initiate a possible
investigation. In instances where the report includes an allegation of
sexual abuse, section 4f of this form should be re-reviewed with the
victim.
Page 3 of the DD2967 will not be completed unless there is a
retaliation report being made.
1. The person making the report of experienced or observed
retaliation will complete this section with the DAVA, DAVA supervisor,
or FAP clinical provider. The reporters full name and DoD
Identification Number (for personnel with Common Access Cards
only) will be completed for purposes of ensuring that the reporting
information is being captured in accordance with Public Law 113-66,
section 1709.
The person reporting the retaliation will acknowledge understanding
sections (a) through (f) under this section. The DAVA, DAVA
supervisor, or FAP clinical provider will explain each item to the
reporting party, as applicable.
2. DESIGNATION OF PERSON REPORTING RETALIATION. This
section specifically identifies the person that is making the report for
purposes of tracking and reporting retaliation received by FAP to the
Secretary of Defense annual IAW Attachment 4 of the October 15,
2019 USD(P&R) Memorandum, Section 1709 of PL 113-66, and
Service FAP headquarters implementing policies and guidance.
(sections 3 and 5).
3. SIGNATURE OF RETALIATION REPORTER. The reporter will
sign and date.
4. SIGNATURE OF FAP CLINICAL PROVIDER OR DAVA AND
PRINT NAME. The DAVA, DAVA supervisor, or FAP clinical provider
will sign, print, and date based on when the report of retaliation was
received.
5. FAP INSTALLATION AND CONTACT INFORMATION. This is the
information for the local FAP and the contact information for the
DAVA, DAVA Supervisor, or FAP clinical provider for tracking
purposes.
6. NOTES: This section will be used to document any applicable
notes or information that you deem necessary and appropriate
associated with the retaliation report only.

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