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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
20091493 Fort Bragg 03MAR2009 11JUN2009 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 EM-04

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 Army

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
Regular EM-04 Not Reported 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
09JUL2009 MetCriteria PHYSICAL: Mild

SECTION VI - CLOSURE

Date Incident Closed by CRC Incident Close Reason


08DEC2009 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