Dd Form 2951 - Initial Report Of Suspected Child Sexual Abuse In Dod Operated Or Sponsored Out-Of-Home Care Activities Page 2

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SECTION B - INFORMATION ON PROBABLE AND POTENTIAL VICTIMS
(If additional information is needed, continue on separate sheet.)
8. PROBABLE VICTIMS
a. NUMBER
b. AGE
c. SEX
d. SPONSOR'S SERVICE
a. NUMBER
b. AGE
c. SEX
d. SPONSOR'S SERVICE
1
6
2
7
3
8
4
9
5
10
10. TOTAL ESTIMATED POTENTIAL VICTIMS
9. POTENTIAL VICTIMS IN OTHER OUT-OF-HOME CARE
ACTIVITIES?
YES
NO
11. ESTIMATED AGE RANGE OF POTENTIAL VICTIMS
12. SPONSORS OF POTENTIAL VICTIMS FROM DIFFERENT
SERVICES?
TO
YES
NO
SECTION C - INFORMATION ON SUBJECT OF THE ALLEGATION
(If additional information is needed, continue on separate sheet.)
13. SEX
14. AGE
15. YEARS AT INSTALLATION
16. CURRENT POSITION WITHIN ACTIVITY
17. EMPLOYMENT STATUS
EMPLOYEE
CONTRACTOR/CONTRACT EMPLOYEE
VOLUNTEER
18. CURRENT POSITION(S) IN OTHER OUT-OF-HOME CARE ACTIVITIES ON INSTALLATION (List all)
19. PREVIOUS POSITION(S) IN OUT-OF-HOME CARE ACTIVITIES ON INSTALLATION (List all)
20. PREVIOUS POSITION(S) IN OUT-OF-HOME CARE ACTIVITIES ON OTHER INSTALLATIONS (List all and provide dates)
21. DATE, TYPES AND RESULTS OF BACKGROUND CHECK(S)
22. STATUS (If additional information is needed, continue on separate sheet.)
a. CURRENT SUBJECT STATUS IN ACTIVITY
b. CURRENT LEGAL STATUS
(1) REASSIGNED (Away from children/youth)
(1) INVESTIGATION OPEN
(2) ON ADMINISTRATIVE LEAVE
(2) CHARGES FILED
(3) RESIGNED/TERMINATED
(3) FUGITIVE
(4) REMAINS IN POSITION
(4) CLOSED INVESTIGATION ONLY
DD FORM 2951 (BACK), JUN 2012
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