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

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

1

Incident #
20091655 Fort Bragg

Installation

Date of Incident Date of Referral
05JUL2009 16JUL2009

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
CIVILIAN: Law Enforcement 0

Number of secondary offenders

Originating Installation for Transfer-In Case

Maltreatment Type(s) Alleged
Physical

Investigation Source
Civilian Law Enforcement

Victim Protective Actions
Other safety actions

SECTION II - SPONSOR INFORMATION

Sponsor SSN
REDACTED

Sponsor Name
REDACTED

Sponsor Role in Incident
Alleged Offender

Sponsor Branch of Service
Army

Sponsor Component
Regular

Sponsor Rank
EM-04

SECTION III - VICTIM INFORMATION

Victim FMP

Victim SSN
REDACTED

Victim Name
REDACTED

Victim Date of Birth
01JAN1920

Victim Sex
Female

Victim Race Ethnicity
White, 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
White, Not Hispanic

Abuser Branch of Service
Army

Abuser Service Component
Regular

Abuser Rank
EM-04

Abuser Marital Status
Single (Never Married)

Is this a dual military marriage?
No

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

Abuser Clinical Intervention Provided by?
Army FAP Providers

Abuser Relationship to Victim
Intimate Partner

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: Mild

SECTION VI - CLOSURE

Date Incident Closed by CRC
. Not Reported

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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