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
20091400 Fort Bragg 30MAY2009 04JUN2009 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: Other 0

Originating Installation Maltreatment Type(s)

for Transfer-In Case Alleged Investigation Source Victim Protective Actions
Physical No Investigation 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 Victim Army Regular OM-02

SECTION III - VICTIM INFORMATION

Victim Victim
Victim Date of Race Marital
Victim FMP Victim SSN Victim Name Birth Victim Sex Ethnicity Status
20 REDACTED REDACTED 01JAN1920 Male White, Not Not
Hispanic 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?
No Substance Involved Substance not Army FAP Providers Yes
Involved

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 Female White, Not Civilian (Include
Hispanic Govt Contr)

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 NO-00 Married No Substance not Substance not
Involved Involved

Abuser Clinical Intervention Abuser Relationship if

Provided by? Abuser Relationship to Victim Extrafamilial Caregiver
Army FAP Providers Spouse Not Reported

SECTION V - DISPOSITION BY CRC

Determination Date
(i.e., CRC Date) Determination Type(s) of Abuse Substantiated
30JUN2009 MetCriteria PHYSICAL: Moderate

SECTION VI - CLOSURE

Date Incident Closed by CRC Incident Close Reason

03DEC2009 Intervention/Treatment no Longer needed

SECTION VII - AUTHENTICATION

Date Incident Closed

by CRC AUTHENTICATING OFFICIAL SIGNATURE
19NOV2010 . Electonically Signed

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974