DD Form 2910-1 Replacement of Lost DD Form 2910 Victim Reporting Prefer

CUI when filled

REPLACEMENT OF LOST DD Form 2910,
VICTIM REPORTING PREFERENCE STATEMENT

OMB No. 0704-0482
OMB Approval Expires:
YYYYMMDD

(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. 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, (Sexual Assault Prevention and Response
Program); 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 the
procedures set up to effectively manage the Sexual Assault Prevention and Response (SAPR) Program. Specifically, the form will document the loss of the
original DD Form 2910 through the request for a replacement form. The form shall document the reaffirmation or change of the original reporting option. At the
local level, Service SAPR Program Management, Major Command Sexual Assault Response Coordinator(s) (SARCs), Installation, and Brigade SARCs use the
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 de-identified data is used to respond to mandated congressional reporting requirements. The DoD Sexual Assault Prevention and Response
Office has access to identified closed case information and de-identified, aggregate open case information for congressional reporting, study, research, and
analysis purposes.
ROUTINE USE(S): The DoD blanket routine uses found at http://dcpio.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx may apply to this record.
Note: Any release made as a blanket routine use will be consistent with the principal purpose of the information’s original collection. Collected information is
covered by Department of Human Resources Activity 06 DoD, Defense Sexual Assault Incident Database
(https:’’dpcid.defense.gov/Privacy/SORNsinex/DOD-wide-SORN-Article-View/Article/570559/dhra-06-dod/.
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

1. REQUESTOR (VICTIM)
I, (Full Name)

DRAFT

(Social Security Number)

and/or (DoD Identification Number)

Requested a copy of the original DD Form 2910 from: [select one]

Sexual Assault Prevention and Response Victim Advocate (SAPR VA) or
Sexual Assault Response Coordinator (SARC)
On

(date the request was made), I have been advised that my original DD Form 2910 cannot be located.

2. DOCUMENTING MY ORIGINAL REPORTING OPTION (Victim initials one of the options)
a. I filed my report at

(date).

(location) on/about

b. When I signed the original DD Form 2910, I elected Unrestricted Reporting.
c. When I signed the original DD Form 2910, I elected Restricted Reporting.
d. When I signed the original DD Form 2910, I elected Restricted Reporting but converted to Unrestricted Reporting
e. When I signed the original DD Form 2910, I elected Restricted Reporting, but I am now choosing to make an Unrestricted Report.
Therefore, I am completing a new DD Form 2910.
This FORM replaces the original DD Form 2910 and may be used by the requestor in other matters before other agencies (e.g.,
Department of Veterans Affairs), to the extent authorized by law.
3. SIGNATURE OF THE REQUESTOR VICTIM

DATE (YYYYMMDD)

COVID RESPONSE

4. SARC OR SAPR VA (print name)

DD FORM 2910-1, DRAFT

SIGNATURE OF SARC OR SAPR VA

PREVIOUS EDITION IS OBSOLETE.
CUI when filled

DATE (YYYYMMDD)

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

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

NO

Victim Initials:

If yes: Date (YYYYMMDD)

Transfer Location:

Signature:

COVID NOTES

DRAFT

DD FORM 2910-1 (BACK), DRAFT

PREVIOUS EDITION IS OBSOLETE.
CUI when filled

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