CHILD/INTIMATE PARTNER ABUSE INCIDENT REPORT 1

For Official Use Only.

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SECTION I - ADMINISTRATIVE DATA

Type of
Incident # Installation Date of Incident Date of Referral Victim
20090102 Fort Bragg 23SEP2008 23SEP2008 Spouse

Was offender in Was deceased Number of

Victim fatality previously victim previously secondary
Status known to FAP? known to FAP? Source of Referral to FAP offenders
Alive No No MILITARY: Medical/Dental 0

Originating Installation Maltreatment Type(s)

for Transfer-In Case Alleged Investigation Source Victim Protective Actions
Physical Blank Other safety actions

SECTION II - SPONSOR INFORMATION

Sponsor Role in Sponsor Branch Sponsor

Sponsor SSN Sponsor Name Incident of Service Component Sponsor Rank
REDACTED REDACTED Alleged Offender Not Reported Not Reported

SECTION III - VICTIM INFORMATION

Victim Victim
Victim Date of Race Marital
Victim FMP Victim SSN Victim Name Birth Victim Sex Ethnicity Status
REDACTED REDACTED 01JAN1920 Not Not Not
Reported Reported Reported

Victim Involved Victim Involved

Victim with Alcohol with Drugs Incident
Permanently Related to Related to Victim Clinical Intervention Occurred in
Disabled? Incident Incident Provided by? Installation?
Not Reported Not Reported Not Reported Unsubstantiated Incident No

SECTION IV - ABUSER INFORMATION

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974

 CHILD/INTIMATE PARTNER ABUSE INCIDENT REPORT 2
For Official Use Only.
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Abuser
Abuser Date of Abuser Race Branch of
Abuser SSN Abuser Name Birth Abuser Sex Ethnicity Service
REDACTED REDACTED 01JAN1920 Not Reported Not Reported Not Reported

Is this a dual Abuser Involved Abuser Involved

Abuser Service Abuser Marital military with Alcohol with Drugs Related
Component Abuser Rank Status marriage? Related to Incident to Incident
Not Reported Not Reported No Not Reported Not Reported

Abuser Clinical Intervention Abuser Relationship if

Provided by? Abuser Relationship to Victim Extrafamilial Caregiver
Unsubstantiated Incident Spouse Not Reported

SECTION V - DISPOSITION BY CRC

Determination Date
(i.e., CRC Date) Determination Type(s) of Abuse Substantiated
15OCT2008 Referred for Services BLANK

SECTION VI - CLOSURE

Date Incident Closed by CRC Incident Close Reason

. Abuser Refused treatment

SECTION VII - AUTHENTICATION

Date Incident Closed

by CRC AUTHENTICATING OFFICIAL SIGNATURE
16NOV2010 . Electonically Signed

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974