Dd Form 2901 - Child Abuse Or Domestic Violence Related Fatality Notification
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4REPORT CONTROL SYMBOL
CHILD ABUSE OR DOMESTIC VIOLENCE RELATED FATALITY NOTIFICATION
DD-P&R(Q)2052
Within 72 hours of being notified of a DoD-related fatality known or suspected to be (1) an act of domestic violence, (2) an act of
child abuse, or (3) an act of suicide related to an act of domestic violence or child abuse, the information about such a fatality shall be
reported through Service or Defense Agency/DoD Field Activity channels to the Deputy Under Secretary of Defense (Military
Community and Family Policy) (DUSD(MC&FP)) by fax to: 571-372-0884 (DSN 332-4977). Information contained on the form must
be coordinated with the criminal investigative organization or law enforcement agency conducting the investigation, in addition to
other offices or agencies having relevant information (e.g. medical examiner's office regarding cause of death). If civilian agencies
have jurisdiction over the incident and are unable to share details about the fatality, information should still be submitted to the DUSD
(MC&FP) in as much detail as possible.
SECTION I - ADMINISTRATIVE INFORMATION
3. REPORT FROM (X one)
1. DATE OF REPORT
2. DATE OF INCIDENT
(YYYYMMDD)
(YYYYMMDD)
ARMY
MARINE CORPS
NAVY
AIR FORCE
DEFENSE AGENCY/DOD FIELD ACTIVITY
4. NAME OF INSTALLATION
5. PERSON MAKING THIS REPORT
a. NAME (Last, First, Middle Initial)
b. TITLE
c. TELEPHONE NUMBER (Include area code)
d. FAX NUMBER (Include area code)
(1) DSN
(2) COMMERCIAL
(1) DSN
(2) COMMERCIAL
7. NUMBER OF FATALITIES
6. INCIDENT TYPE (X)
8. LOCATION OF INCIDENT (X)
CHILD ABUSE
OFF INSTALLATION
ON INSTALLATION
a. HOMICIDE
b. SUICIDE
DOMESTIC VIOLENCE
IN VICTIM'S HOME
RELATED SUICIDE
OTHER
SECTION II - SUSPECT INFORMATION
9. SUSPECT NUMBER
10. AGE
11. GENDER (X one)
MALE
FEMALE
OF
12. RELATIONSHIP TO DOD (X one)
13. SERVICE (X one)
ACTIVE DUTY
PAY GRADE:
ARMY
MARINE CORPS
CURRENT DEPENDENT OF ACTIVE DUTY MEMBER
NAVY
AIR FORCE
CIVILIAN EMPLOYEE
OTHER
CIVILIAN WITH NO DOD AFFILIATION
NOT APPLICABLE
14. WAS THE SUSPECT PREVIOUSLY REPORTED TO COMMAND
15. IS THE SUSPECT CURRENTLY IN MILITARY RESTRAINT OR
FOR ALLEGED FAMILY VIOLENCE? (X one)
CIVILIAN CUSTODY? (X one)
YES
NO
UNKNOWN
YES
NO
UNKNOWN
SECTION III - VICTIM INFORMATION
16. VICTIM NUMBER
17. AGE
18. GENDER (X one)
OF
MALE
FEMALE
19. RELATIONSHIP TO DOD (X one)
20. SERVICE (X one)
ACTIVE DUTY
PAY GRADE:
ARMY
MARINE CORPS
CURRENT DEPENDENT OF ACTIVE DUTY MEMBER
NAVY
AIR FORCE
CIVILIAN EMPLOYEE
OTHER
CIVILIAN WITH NO DOD AFFILIATION
NOT APPLICABLE
21. RELATIONSHIP TO SUSPECT (X one)
22. SUSPECTED CAUSE OF DEATH (X one)
CHILD
GUNSHOT
POISON
SPOUSE
STABBING
BURNS
FORMER SPOUSE
STRANGULATION
OTHER
CURRENT INTIMATE PARTNER
BLUNT TRAUMA
FORMER INTIMATE PARTNER
SHAKING
UNKNOWN
SELF
SUFFOCATION
24. WAS VICTIM PREVIOUSLY KNOWN TO THE FAMILY ADVOCACY PROGRAM? (X one)
23. DATE OF DEATH (YYYYMMDD)
YES
NO
UNKNOWN
DD FORM 2901, MAY 2012
PREVIOUS EDITION IS OBSOLETE.
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