Fillable Dd Form 2967 - Domestic Abuse Victim Reporting Option Statement printable pdf download

DOMESTIC ABUSE VICTIM REPORTING OPTION STATEMENT

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

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136 and DoD Instruction 6400.06, Domestic Abuse Involving DoD Military and Certain Affiliated Personnel.

PRINCIPAL PURPOSE(S): Information on this form documents your decision of whether to file a restricted or unrestricted report of

domestic abuse. This document is filed in accordance with the appropriate Military Department Family Advocacy Program System of

Records Notice (SORN). The SORNs are:

Air Force:

Navy: http//dpclo.defense.gov/privacy/SORNs/component/navy/N01752-1.html;

Army: http//dpclo.defense.gov/privacy/SORNs/component/army/A0608-18_DASG.html.

ROUTINE USE(S): Please check the appropriate SORN (link provided above) to review specific Military Department routine uses.

The DoD "Blanket Routine Uses" listed at may apply to this

document. Any release made pursuant to a "blanket routine use" will be reviewed to ensure the release is appropriate and consistent

with the purpose for which the record was collected.

DISCLOSURE: Voluntary; however, if you decide not to provide certain information, it may impede the ability of the Military

Department to provide effective management of care and support to you which have been established by the procedures of the

domestic abuse prevention and response program.

1. REPORTING PROCESS AND OPTIONS DISCUSSED WITH THE VICTIM ADVOCATE

I, (Full name)

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

VA Supervisor, or Healthcare Provider (HCP) before selecting a reporting option.

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

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 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 offender or receiving a

military protective order against the offender.

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

INITIALS

a. I understand that I can confidentially receive medical treatment, advocacy services, and counseling, but law

enforcement and command will NOT be notified. My report will NOT trigger an investigation; therefore, no

action will be taken against the offender as the result of my report.

INITIALS

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

of my abuse may be revealed to satisfy the exception.

INITIALS

c. I understand that all state laws, local laws or international agreements that may limit some or all of DoD's restricted

, medical

reporting protections have been explained to me. In

authorities must report the domestic abuse to

INITIALS

d. I understand that the VA or his/her supervisor will provide information that does not reveal my identity, nor that of

my offender, to the responsible senior commander. This information is required for the purposes of public safety

and providing command a clear picture of the type of domestic abuse incidents within their command to enhance the

ability of command 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 the offender or receiving a military protective order against the offender.

INITIALS

f. I understand that if I talk about my abuse to anyone other than designees under the "Restricted Reporting" option

(VA, VA supervisor, or HCP), it may be reported to my command and law enforcement which could lead to an

investigation.

INITIALS

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

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

If the case goes to court, my VA and others providing care may be called to testify about any information I shared

with them.

INITIALS

h. I understand that if I do not choose a reporting option at this time, the commander or designated person within the

chain of command and law enforcement will be notified.

DD FORM 2967, AUG 2013

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Dd Form 2967 - Domestic Abuse Victim Reporting Option Statement

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