DD Form 2910 Victim Reporting Preference Statement

CUI when filled
OMB No. 0704-0482
OMB Approval Expires:
YYYYMMDD

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 ## hours/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, 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 Office of Management and Budget control number.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 932, Art. 132 Retaliation, 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness: 10 U.S.C. 7013, Secretary of 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, (Sexual Assault Prevention and Response Program); Army
Regulation 600-20 (Army Command Policy) Chapter 7, Office of the Chief of Naval Operations (OPNAV) Instruction 1752.1C, Sexual Assault Prevention and Response 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): Information will be used to document elements of the sexual assault response and/or reporting process and comply with procedures set up to effectively
manage the Sexual Assault Prevention and Response Program.
ROUTINE USE(S): Applicable Routine Use(s) are: To permit the disclosure of records of closed cases of unrestricted reports to the Department of Veterans Affairs (DVA) for purpose
of providing mental and medical care to former Service members, to determine the eligibility for or entitlement to benefits, and to facilitate collaborative research activities between the
DoD and DVA. Additional routine uses are listed in the applicable system of records notice, DHRA 06, Defense Sexual Assault Incident Database (DSAID), at https:
dpcid.defense.gov/Privacy/SORNsinex/DOD-wide-SORN-Article-View/Article/570559/dhra-06-dod/.

DSAID CONTROL NUMBER
RR-

UU-

RU-

Post Transfer-

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

(SSN)

and (DoD Identification Number)

B. ELIGIBILITY WAS EXPLAINED AND THE FOLLOWING INFORMATION WAS PROVIDED, PLEASE INITIAL BELOW
(1) The services, protective orders, and reporting options that are available.
(2) If my case is prosecuted in a civilian jurisdiction there will be different procedures, e.g. SAFE kit retention.
(3) Eligibility for a Special Victims' Counsel or Victims' Legal Counsel (SVC/VLC) who will be my attorney and not the government’s attorney, and who will provide me with
legal advice and representation.
(4) The SARC/SAPR VA has informed me of available support services, to include mental health providers, and chaplain resources.
(5) Please initial here if this sexual assault occurred PRIOR TO ENTRY into military service (includes both as child or adult).
(6)(a) Is this your home installation?

Yes

No

DRAFT

(b) If not, here is the contact information for your local SARC (name/phone number)

(information can be found on the Safe Helpline under “responders near me” at https://safehelpline.org/responders-search)
(7) In accordance with DoD policy, if reporting a sexual assault that occurred prior to or while not performing active or inactive training, National Guard and Reserve
Component members are eligible to receive SAPR advocacy support services from a SARC and SAPR VA and are eligible to file both a Restricted or Unrestricted
Report.
(a) Are you a National Guard member?
(b) If so, what status are you on?

Yes

Title 10 or

No

Title 32

(c) If a National Guard victim does not wish to speak to their local SARC, they can email the National Guard Bureau (NGB) headquarters at [email protected]. This email box is encrypted and monitored by 8 Regional Program Managers and two Branch Chiefs (All of which are D-SAACP Credentialed). Even
though the email has an Army address, this Mailbox is a Joint Mailbox as NGB handles both Army Guard and Air Guard situations; the email is located on an Army
network for convenience only.
(d) SARCs conducting the DD Form 2910 intake should contact the NGB mailbox at [email protected] to facilitate a warm hand-off to the home
National Guard SARC, if this is desired by the victim. The SARC can also contact the mailbox to start the Line of Duty (LOD) determination process, since regardless of
mobilization status, LOD's for National Guard victims must be processed by NGB.

C. UNRESTRICTED REPORTING – REPORTING A CRIME WHICH IS INVESTIGATED (Initial)
(1) Law enforcement and my command will be notified that I am a victim of a sexual assault. Military Criminal Investigative Organization (MCIO) investigator (e.g., CID,
NCIS, AFOSI) or the appropriate civilian law enforcement agency will investigate. I can receive medical treatment, support services, counseling, and a Sexual Assault
Forensic Examination (SAFE) if indicated. A Case Management Group will track my Unrestricted Report and provide a status report. In a UCMJ case, I will be provided
a DD Form 2701 (which contains important information about my rights as a victim) from law enforcement or MCIO. I should retain the DD Form 2701.
(2) 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) I may request a Military Protective Order (MPO), and if issued against a service member, my commander will provide me a copy of DD Form 2873.
(4) I also have the option of requesting a Civilian Protection Order (CPO) from a civilian court.
(5) If the crime is prosecuted under the Uniform Code of Military Justice (UCMJ), any communications with my SARC or SAPR VA, for the purpose of facilitating advice or
assistance, are confidential under the Victim-Victim Advocate Privilege unless an exception applies under the UCMJ.

D. RESTRICTED REPORTING – CONFIDENTIALLY REPORTING A CRIME WHICH IS NOT INVESTIGATED (Initial)
(1) I may confidentially receive medical/mental health treatment, advocacy, and legal services. Law enforcement and my command will NOT be notified and the crime will
NOT be investigated. No action will be taken against the suspect(s).
(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 that state laws, local laws or international agreements may limit some or all DoD's Restricted Reporting protections. In the (state, city/county) of
, civilian medical authorities must report the sexual assault when a victim reports or undergoes a SAFE.
(4) I may choose to have a SAFE.
(5) Evidence collected from my SAFE will be stored for 10 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. Evidence collected by a civilian medical facility will be stored per established Memorandum of Understanding (MOU) with DoD or per
state or local laws. I will be contacted in 1 year by my SARC to discuss my options as they relate to this evidence.
(6) For public safety reasons, the SARC will provide assault information that does not reveal my identity or the suspect’s to the installation commander.
(7) Expedited transfers and protective orders against the subject will NOT be available to me if I choose Restricted Reporting. I still have the option for SVC/VLC.
(8) Communications with chaplains and SVC/VLCs are protected by law, if those communications were conducted for the appropriate purpose.
(9) I may change my Restricted Report to an Unrestricted Report, at any time. However, delays in changing my report from Restricted to Unrestricted could impact the
investigation and judicial process.

DD FORM 2910, DRAFT
PREVIOUS EDITION IS OBSOLETE.

CUI when filled

Page 1 of 3
Controlled by: OUSD(P&R)
CUI Category: PRVCY
LDC: FEDCON
POC: [email protected]

CUI when filled
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 participating officials. The report may be disclosed to these parties when it is required for
fitness for duty or disability retirement determinations. Disclosure is limited to only that information necessary to make a determination for disability.
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.
E. The exceptions to Restricted Reporting have been explained to me.

Yes

No

F. OTHER IMPORTANT CONSIDERATIONS FOR UNRESTRICTED AND RESTRICTED REPORTS (Initial)
(1) If I do not sign this form, the SARC or SAPR VA will not inform investigators, commanders, or others about my sexual assault.
(2) I have the right to decline any or all SAPR advocacy 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, when
applicable, this form will be stored electronically in DSAID for 50 years. 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 if I experience retaliation from supervisors or peers, I can report to the SARC or SAPR-VA through DD form 2910-2 (If I filed an Unrestricted Report).
I can also report it to SVC/VLCs, my commander, law enforcement, Victim Witness Assistance Program, EO or EEO personnel, or the Inspector General.
(5) 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 report (e.g., underage drinking).
(6) For information on the Catch a Serial Offender (CATCH) Program, eligibility to participate, and notification procedures after a “match” in the CATCH system – go to page
3.
(7) For information about legal resources from civilian legal services organizations please go to https://www.va.gov/ogc/legalservices.asp.

2. CHOOSE A REPORTING OPTION (Initial either A. or B.)

DRAFT

A. I elect Unrestricted Reporting. I have decided to report that I am a victim of sexual assault and I understand that my command, law enforcement, and other military
authorities will be notified.
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:

B. DATE (YYYYMMDD)

3.A. SIGNATURE OF VICTIM

4.A. SIGNATURE OF SARC/SAPR VA

B. DATE (YYYYMMDD)

COVID NOTES
COVID RESPONSE

5. CONVERSION: I have reconsidered my previous selection of Restricted Reporting and am now choosing to make an Unrestricted Report.
B. DATE (YYYYMMDD)

A. SIGNATURE OF VICTIM

C. SIGNATURE OF SARC/SAPR VA

D. DATE (YYYYMMDD)

COVID NOTES
COVID RESPONSE

6. My reason for converting my Restricted Report to an Unrestricted Reporting is:

CATCH Program

Other, please explain:

7.A.

Yes

7.B.

(For SARCs only, if victim replied “yes” to 7.A.) I not only made the conversion from RR to UR in DSAID, but I confirm that I also made the update in the CATCH
website.

No

I filed a previous CATCH entry.

7.C. SIGNATURE OF SARC

7.D. DATE (YYYYMMDD)

8. VICTIM CONSENTED TO TRANSFER OF (RR/UR) CASE TO ANOTHER SARC. NOT APPLICABLE FOR EXPEDITED TRANSFERS: (X and complete as applicable)
Yes

No

If yes: Date (YYYYMMDD)

Transfer Location:

Victim Initials

9. VICTIM CONTACTED AT 1-YEAR MARK OF THE RESTRICTED REPORT: (X and complete as applicable)
Yes

No

If yes: Date (YYYYMMDD)

If not, document how the SARC attempted to locate the victim. Phone/Email:

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

Yes

No

If yes: Date (YYYYMMDD)

11. VICTIM REQUESTED A COPY OF THE FORENSIC EXAMINATION
DOCUMENTATION: (X and complete as applicable)
Yes

No

If yes: Date (YYYYMMDD)

Please proceed to page 3 -- to provide sexual assault victims with
information regarding Veterans Affairs services and the Catch a Serial Offender Program.
DD FORM 2910, DRAFT
PREVIOUS EDITION IS OBSOLETE.

CUI when filled

Page 2 of 3

CUI when filled
12. Department of Veterans Affairs Information
Pls. Initial:
A. I was advised that as a current Service member, I am eligible for Department of Veterans Affairs (VA) services for military sexual trauma (MST). Information on VA’s
MST-related services for current and former Service Members is available at http://www.mentalhealth.va.gov/mst.
B. Read below to get information on how the VA can help you with medical and mental health care and, if you are interested in filing a disability claim.
(1) Medical and mental health care: I was advised that every VA health care facility has a Veterans Health Administration (VHA) MST Coordinator who can assist me in
accessing MST-related medical and mental health care, and information is available at: http://www.mentalhealth.va.gov/msthome/vha-mst-coordinators.asp.
(2) Benefits and Disability claims: I was advised that for help with disability claims related to MST, I can contact the Veterans Benefits Administration (VBA) MST
Outreach Coordinator at my local VBA Regional Office, and information is available at: www.benefits.va.gov/benefits/mstcoordinators.asp.
C. I am retiring or separating from the Armed Forces:

Yes

No

(1) If yes, I have been provided the name and contact information of the VHA MST Coordinator nearest to my residence to get MEDICAL/MENTAL HEALTH care
information, see below: (List of VHA MST Coordinators by state is available at: http://www.mentalhealth.va.gov/msthome/vha-mst-coordinators.asp. VHA Website
only provides the name and phone number of POC.
(name of MST Coordinator)
(phone)
(2) If yes, I have been provided the name and contact information of the VBA MST Coordinator nearest to my residence to get BENEFITS/DISABILITY CLAIMS
information, see below: (List of VBA MST Coordinators by state is available at: http://www.benefits.va.gov/benefits/mstcoordinators.asp. VBA Website only provides
the name and the email of the POC.
(name of MST Coordinator)
(email),

13. Sexual Violence and Support Experiences Study
The Department of Defense is extremely interested in making sure that we provide you the best support we can. I understand that I can learn more about how to provide
confidential feedback about my experiences with the military response system and the support I receive by visiting www.SAPR.mil/SVSES. Participation is my choice. This
study was recommended by the 2019 Sexual Assault Accountability and Investigation Task Force.

14. Confirmation That Victim Did Not Previously Submit A Catch Entry On This Same Suspect For This Same Sexual Assault

DRAFT

A. I confirm that I have not submitted another CATCH entry on this same suspect for this same sexual assault through a CATCH SRI Entry using DD Form 2910-4. (You
may have approached a SARC and did not want to officially report the sexual assault, but did want to submit a CATCH entry).
B. I confirm that I have not submitted another CATCH entry on this same suspect for this same sexual assault, when I previously reported my sexual assault and filled out a
DD Form 2910.

15. Information regarding the Catch a Serial Offender (CATCH) Program:
A. I have been informed about and elect:

To participate in the CATCH Program.

Not to participate in the CATCH Program.

B. I have been informed that additional information on the CATCH program can be found at www.SAPR.mil/CATCH
C. As a participant in the CATCH Program, I agree to provide the following contact information:
Phone/Email:

Phone/Email:

D. Type of sexual assault report I filed:
I filed a Restricted Report RR DSAID Control Number:
I filed an Unrestricted Report (but law enforcement does not know the name of the suspect) UR DSAID Control Number:
Corresponding MCIO case number (if available in DSAID):

16. Notification of victim after a “MATCH” in the Catch a Serial Offender (CATCH) system:
A. I originally filed a Restricted Report, after a “MATCH” in the CATCH database, I have decided to:
(1) Convert my report to an Unrestricted Report (UR) by re-signing the DD Form 2910
(Victim Initials)

Signature

Date

(2) Decline to convert to UR, but agreed to be contacted again if another “MATCH”:
(SARC Name)

(SARC Initials)

Date

(3) Decline to convert to UR and also Opt Out of the CATCH program:
(SARC Name)

(SARC Initials)

Date

B. I originally filed an Unrestricted Report (UR), after a “MATCH” in the CATCH database I have decided to:
(1) Participate in the investigation: (Victim Initials)

Signature

Date

(2) Decline to participate in the investigation, but agreed to be contacted again if another “MATCH”:
(SARC Name)

(SARC Initials)

Date

(3) Decline to participate in the investigation and also Opt Out of the CATCH program:
(SARC Name)

(SARC Initials)

Date

C. After a “MATCH” in the CATCH database, SARC unable to contact victim after these three attempts:
(1) (SARC Name)

(SARC Initials)

Date

(2) (SARC Name)

(SARC Initials)

Date

(3) (SARC Name)

(SARC Initials)

Date

DD FORM 2910, DRAFT
PREVIOUS EDITION IS OBSOLETE.

CUI when filled

Page 3 of 3