CHILD/INTIMATE PARTNER ABUSE INCIDENT REPORT For Official Use Only.

---------------------------------------------------------------------------------------------------SECTION I - ADMINISTRATIVE DATA

1

Incident #
20091624 Fort Bragg

Installation

Date of Incident Date of Referral
12JUL2009 13JUL2009

Type of Victim
Spouse

Victim Status
Alive

Was offender in fatality previously known to FAP?
No

Was deceased victim previously known to FAP?
No

Source of Referral to FAP
MILITARY: Medical/Dental 0

Number of secondary offenders

Originating Installation for Transfer-In Case

Maltreatment Type(s) Alleged
Physical

Investigation Source
No Investigation

Victim Protective Actions
Other safety actions

SECTION II - SPONSOR INFORMATION

Sponsor SSN
REDACTED

Sponsor Name
REDACTED

Sponsor Role in Incident
Victim

Sponsor Branch of Service
Army

Sponsor Component
Regular

Sponsor Rank
EM-03

SECTION III - VICTIM INFORMATION

Victim FMP
20

Victim SSN
REDACTED

Victim Name
REDACTED

Victim Date of Birth
01JAN1920

Victim Sex
Female

Victim Race Ethnicity
Black, Not Hispanic

Victim Marital Status
Not Reported

Victim Permanently Disabled?
No

Victim Involved with Alcohol Related to Incident
Substance not Involved

Victim Involved with Drugs Related to Incident
Substance not Involved

Victim Clinical Intervention Provided by?
Army FAP Providers

Incident Occurred in Installation?
No

SECTION IV - ABUSER INFORMATION

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974

CHILD/INTIMATE PARTNER ABUSE INCIDENT REPORT For Official Use Only. ---------------------------------------------------------------------------------------------------Abuser Date of Birth
01JAN1920

2

Abuser SSN
REDACTED

Abuser Name
REDACTED

Abuser Sex
Male

Abuser Race Ethnicity

Abuser Branch of Service

Black, Not Hispanic Civilian (Include Govt Contr)

Abuser Service Component
Not Reported

Abuser Rank

Abuser Marital Status
Married

Is this a dual military marriage?
No

Abuser Involved Abuser Involved with Alcohol with Drugs Related Related to Incident to Incident
Substance Involved Substance not Involved

Abuser Clinical Intervention Provided by?
Blank

Abuser Relationship to Victim
Spouse

Abuser Relationship if Extrafamilial Caregiver
Not Reported

SECTION V - DISPOSITION BY CRC

Determination Date (i.e., CRC Date)
11AUG2009 MetCriteria

Determination

Type(s) of Abuse Substantiated
PHYSICAL: Moderate

SECTION VI - CLOSURE

Date Incident Closed by CRC
16SEP2009 Victim refused treatment

Incident Close Reason

SECTION VII - AUTHENTICATION

Date Incident Closed by CRC
19NOV2010 .

AUTHENTICATING OFFICIAL

SIGNATURE
Electonically Signed

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974

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