Dd Form 2967 - Domestic Abuse Victim Reporting Option Statement Page 2
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24. CHOOSE A REPORTING OPTION
INITIALS
a. Unrestricted Report. I elect Unrestricted Reporting and have decided to report that I am a victim of domestic abuse
to command, law enforcement, or other military authorities for investigation of this crime.
INITIALS
b. Restricted Report. I elect Restricted Reporting and have decided to confidentially report that I am a victim of
domestic abuse. The command will NOT be provided with information about my identity. 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 punish an offender.
5.
RESTRICTED REPORT CASE NUMBER (If applicable)
6.a. SIGNATURE OF VICTIM
b. DATE
(YYYYMMDD)
7.a. SIGNATURE OF VICTIM ADVOCATE, VICTIM ADVOCATE SUPERVISOR, OR HEALTHCARE
b. DATE
(YYYYMMDD)
PROVIDER
8. I have reconsidered my previous selection of "Restricted Reporting," and I would like to make an "Unrestricted Report" of my
domestic abuse to authorities for a possible investigation.
a. SIGNATURE OF VICTIM
b. DATE
(YYYYMMDD)
c. SIGNATURE OF VICTIM ADVOCATE, VICTIM ADVOCATE SUPERVISOR, OR HEALTHCARE
d. DATE
(YYYYMMDD)
PROVIDER
EXCEPTIONS TO "RESTRICTED REPORTING"
In cases in which a victim elects restricted reporting, the prohibition on disclosing covered communications to the following persons or
entities will be suspended when disclosure would be for the following reasons:
1. Named individuals when disclosure is authorized by the victim in writing.
2. Command officials or law enforcement when necessary to prevent or lessen a serious and imminent threat to the health or safety
of the victim or another person, including dependent children.
3. FAP and any other agencies authorized by law to receive reports of child abuse or neglect when, as a result of the victim's
disclosure, the VA or HCP has a reasonable belief that child abuse has also occurred. However, disclosure will be limited only to
information related to the child abuse.
4. Disability Retirement Boards and officials when disclosure by a HCP is required for fitness for duty for disability retirement
determinations, limited to only that information which is necessary to process the disability retirement determination.
5. Supervisors of the VA or HCP when disclosure is required for the supervision of direct victim treatment or services.
6. Military or civilian courts of competent jurisdiction when a military, Federal or State judge issues a subpoena for the covered
communications to be presented to the court or to officials or entities when the judge orders such disclosure; or to other officials
or entities when required by Federal or State statute or applicable U.S. international agreement.
DD FORM 2967 (BACK), AUG 2013
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