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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
20090016 Fort Bragg 26SEP2008 29SEP2008 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 Other 0

Originating Installation Maltreatment Type(s)


for Transfer-In Case Alleged Investigation Source Victim Protective Actions
Physical Civilian Law Enforcement 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 EM-05

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 Black, 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 not Substance not Army FAP Providers No
Involved 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 Black, Not Hispanic 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 Divorced No Substance not Substance not
Involved Involved

Abuser Clinical Intervention Abuser Relationship if


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

SECTION V - DISPOSITION BY CRC

Determination Date
(i.e., CRC Date) Determination Type(s) of Abuse Substantiated
23OCT2008 MetCriteria PHYSICAL: Mild

SECTION VI - CLOSURE

Date Incident Closed by CRC Incident Close Reason


18JUN2009 Victim 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