Dd Form 2710 - Prisoner Background Summary
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5REPORT DATE
(YYYYMMDD)
PRISONER BACKGROUND SUMMARY
SECTION 1 - PERSONAL DATA
PRIVACY ACT STATEMENT
AUTHORITY: Chapter 48, title 10 U.S.C., Military Correctional Facilities, and DoD Instruction 1325.07.
PRINCIPAL PURPOSE(S): To collect a new prisoner's personal history to assist in the classification and assignment process. The information will
also be used to evaluate progress toward rehabilitation or suitability for parole or clemency.
ROUTINE USE(S): To the Department of Justice and U.S. Probation Officers for annual statistical data analysis. To the Bureau of Prisons (BOP)
when a prisoner is transferred to its custody for incarceration.
DISCLOSURE: Voluntary; however, failure to provide the requested information may prevent the staff of the correctional facility from fully evaluating
the prisoner.
UPON COMPLETION OF THE DD FORM 2710, DETACH PAGE #5 AND MAINTAIN IN THE PRISONER'S MEDICAL RECORDS.
1. NAME
2. REGISTRATION NUMBER
(Last, First, Middle)
3. MAIDEN NAME
4. NICKNAME
5. ALIAS(ES)
6. AGE
7. SEX:
8. PLACE OF BIRTH
9. DATE OF BIRTH
(City, County and State)
(YYYYMMDD)
FEMALE
MALE
10. RACE
11. ETHNICITY
(X one or more) (If prisoner does not fill out or answer questions 10 and 11, reviewer will mark "UNKNOWN".)
(X one)
AMERICAN INDIAN/ ALASKA NATIVE
HISPANIC OR LATINO
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
ASIAN
WHITE
NOT HISPANIC OR LATINO
BLACK OR AFRICAN AMERICAN
UNKNOWN
UNKNOWN
12. NATIONALITY
13. RELIGION
14. HEIGHT
15. WEIGHT
16. IDENTIFYING MARKS
(Scars, tattoos, etc.) (If Yes, see attached)
NO
YES
17. HAIR COLOR
18. EYE COLOR
(X one)
(X one)
AUBURN
BROWN
SILVER
BLACK
GREEN
VIOLET
BLACK
GRAY
WHITE
BLUE
GRAY
BLOND
RED
BALD
BROWN
HAZEL
19. GANG ASSOCIATION:
GANG NAME/LOCATION (City, State)
NO
YES
20. CULT/EXTREMIST ASSOCIATION:
CULT NAME/LOCATION (City, State)
NO
YES
21. DOES YOUR FAMILY KNOW YOUR WHEREABOUTS?
NO
YES
22. DO THEY NEED TO BE NOTIFIED?
NO
YES (If Yes, Name, Relationship, Phone)
23.a. HAVE YOU EVER TRIED TO COMMIT SUICIDE?
b. DO YOU FEEL SUICIDAL AT THIS TIME?
NO
YES
NO
YES
24. ARE THERE ANY ISSUES THAT NEED IMMEDIATE MEDICAL ATTENTION?
(Communicable disease or disabilities)
25. ARE THERE ANY ISSUES THAT NEED IMMEDIATE ATTENTION?
26.a. FORM COMPLETED BY
b. DATE (YYYYMMDD)
c. TIME
(Last Name, First, Middle Initial/Grade)
27. ACTIONS TAKEN IF NECESSARY
28.a. ACTION TAKEN BY
b. DATE (YYYYMMDD)
c. TIME
(Last Name, First, Middle Initial/Grade)
DD FORM 2710, MAR 2013
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 5 Pages
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