Fillable Dd 2910, 2008, Victim Reporting Preference Statement printable pdf download

VICTIM REPORTING PREFERENCE STATEMENT

(Please read Privacy Act Statement before completing this form.)

1. REPORTING PROCESS AND OPTIONS DISCUSSED WITH THE VA OR SARC

a. I, (Full name)

, had the opportunity to talk with a Victim Advocate (VA)

or a Sexual Assault Response Coordinator (SARC) before selecting a reporting option.

b. UNRESTRICTED REPORTING - REPORTING A CRIME WHICH IS INVESTIGATED.

INITIALS

I understand that law enforcement and my command will be notified that I am a victim of sexual assault and an

investigation will be started. I understand I can receive medical treatment, advocacy services, and counseling, and an

optional sexual assault forensic examination to collect evidence if indicated. The full range of victim protection actions

may be available to me, such as being separated from the offender(s) or receiving a military protective order against the

offender. Any misconduct on my part may be punished, but at the discretion of the commander may be delayed until

after the sexual assault charge(s) is resolved.

c. RESTRICTED REPORTING - CONFIDENTIALLY REPORTING A CRIME WHICH IS NOT INVESTIGATED.

(1) I understand that I can confidentially receive medical treatment, advocacy services, and counseling, and an optional

sexual assault forensic exam to collect evidence if needed, but law enforcement and my command will NOT be

notified. My report will NOT trigger an investigation; therefore, no action will be taken against the offender(s) as the

result of my report.

(2) I understand that there are exceptions to "Restricted Reporting" (see back). If an exception applies, limited details

of my assault may be revealed to satisfy the exception.

(3) I understand that if I have not made an "Unrestricted Report" within 1 year of any evidence collected, it will be

destroyed and no longer available for any future investigation or prosecution efforts.

(4) I understand that all state laws, local laws or international agreements that may limit some or all of DoD's restricted

reporting protections have been explained to me. In

, medical

authorities must report the sexual assault to

(5) I understand that the SARC will provide information that does not reveal my identity, nor that of my offender, to the

responsible senior commander within 24 hours of my "Restricted Report" or within 48 hours if at a deployed location

and extenuating circumstances apply. This information is required for the purposes of public safety and command

responsibility.

(6) I understand that by choosing "Restricted Reporting," the full range of victim protection actions may not be available,

such as being separated from the offender(s) or receiving a military protective order against the offender(s).

(7) I understand that if I talk about my sexual assault to anyone other than those under the "Restricted Reporting" option

(SARC, sexual assault victim advocate, or healthcare providers), and chaplains, it may be reported to my command

and law enforcement which could lead to an investigation.

(8) I understand that I may change my mind and report this offense at a later time as an "Unrestricted Report," and law

enforcement and my command will be notified. Delayed reporting may limit the ability to prosecute the offender(s).

If the case goes to court, my victim advocate and others providing care may be called to testify about any information

I shared with them.

(9) I understand that if I do not choose a reporting option at this time, my commander and investigators will be notified.

PRIVACY ACT STATEMENT

AUTHORITY: Section 301 of Title 5, United States Code. and Chapter 55 of Title 10, United States Code.

PRINCIPAL PURPOSE(S): Information on this form 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 program.

ROUTINE USE(S): None.

DISCLOSURE: Completion of this form is voluntary; however, failure to complete this form with the information requested impedes

the effective management of care and support required by the procedures of the sexual assault prevention and response program.

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Dd 2910, 2008, Victim Reporting Preference Statement

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