Form DD Form 2910-2 DD Form 2910-2 Retaliation Reporting Statement for Unrestricted Sexual

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

RETALIATION REPORTING STATEMENT FOR UNRESTRICTED SEXUAL ASSAULT CASES
(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 OMB 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 8, Office of
the Chief of Naval Operations (OPNAV) Instruction 1752.1C, Sexual Assault Prevention and Response Program; Marine Corps Order 1752.5B, 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 reports of retaliation and elements of the response related to retaliation reports when the retaliation is associated with an Unrestricted Report of
sexual assault. SAPR Program personnel use information to ensure that victims are aware of available services. At the DoD level, only de-identified data is used to respond to mandated congressional reporting
requirements.
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-06dod/
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 advocacy services or healthcare (medical and mental health) because you selected Restricted Reporting option. The Social Security Number (SSN) is one of several
unique personal identifiers that may be provided. This form will be retained for 50 years

UR DSAID Case #

RETALIATION CASE NUMBER

1. Retaliation Reporting Process Discussed with SARC or SAPR VA:
I, (Full Name)

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

and/or Social Security Number (not required if DoD Identification Number is provided)

met with a Sexual Assault Response Prevention and

Response Victim Advocate (SAPR VA) or a Sexual Assault Response Coordinator (SARC) to discuss retaliation experienced by me.
INITIALS
(1) The SARC or SAPR VA discussed available resources with me to report instances of retaliation, reprisal, ostracism, or maltreatment, and, if I am interested, the process
to request an Expedited Transfer. {Resources listed in Enclosure 4 of DoDI 6495.02}
(2) The SARC/SAPR VA has informed me of available support services, to include mental health providers, and chaplain resources.
(3) The SARC or SAPR VA 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.
(4) The SARC or SAPR VA explained that I can go to an Inspector General at any time during the process to discuss and report retaliation. This DD Form 2910-2 is NOT a
report to the IG – it is a Retaliation report in the SAPR Program ONLY. 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/AdministrativeInvestigations/DoD-Hotline/

DRAFT

(5) 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 SARC or SAPR VA 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 PlanSexual Assault” [hereafter 24 January 2018 P&R Retaliation Memo]".
(6) If I am a Service member and I believe that there were impacts to my military career because I reported retaliation, the SARC or SAPR VA 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].
Initial one, but not both
(7)

Yes

No

I consent to my allegation of retaliation being discussed at the monthly Case Management Group meeting.

(8) I have reconsidered my earlier refusal of having my allegation of retaliation being discussed at the
CMG. I now consent to have my case discussed.

(SARC Initials)

Date

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 assault
(2) Adult Sexual Assault Victim’s adult family member, please specify the relationship to the sexual assault victim (i.e., spouse, son, daughter, etc.):
(3) Witness
(4) Bystander (who intervened)
(5) SARC on this case
(6) SAPR VA on this case
(7) Responder, please specify the type of responder:
(8) Other individual associated with the incident, please specify (i.e. friend, co-worker, etc.)
3. SIGNATURE OF RETALIATION REPORTER

DATE (YYYYMMDD)

COVID RESPONSE
4. SIGNATURE OF SARC OR SAPR VA and Print Name

DATE (YYYYMMDD)

COVID NOTES
5. SARC INSTALLATION AND CONTACT INFORMATION:

6. ADDITIONAL NOTES OR UPDATES: (Use this section to add any needed notes or updates. Example: “[include date] The Retaliation Reporter initially gave consent to have their
allegation discussed at the monthly CMG and now has changed their mind and rescinds consent to discuss at CMG".)

DD FORM 2910-2, DRAFT
PREVIOUS EDITION IS OBSOLETE.

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Controlled by: OUSD(P&R)
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CUI Category: PRVCY
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