CREW: Department of Defense: Regarding Domestic Violence - Department of The Army: 12/9/2010 - BRAGG 20092015 2201
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CREWCREW: Department of Defense: Regarding Domestic Violence - Department of The Army: 12/9/2010 - BRAGG 20092015 2201
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CREWCHILD/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
20092015 Fort Bragg 06SEP2009 15SEP2009 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 CIVILIAN: Law Enforcement 0
Originating Installation Maltreatment Type(s)
for Transfer-In Case Alleged Investigation Source Victim Protective Actions
Physical & Emotional Blank 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 Neither 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
31 REDACTED REDACTED 01JAN1920 Female 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?
Not Reported 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 Male Black, Not Hispanic Civilian (Include
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 Single (Never No Substance not Substance not
Married) Involved Involved
Abuser Clinical Intervention Abuser Relationship if
Provided by? Abuser Relationship to Victim Extrafamilial Caregiver
Army FAP Providers Intimate Partner Not Reported
SECTION V - DISPOSITION BY CRC
Determination Date
(i.e., CRC Date) Determination Type(s) of Abuse Substantiated
20OCT2009 MetCriteria EMOTIONAL: Mild
SECTION VI - CLOSURE
Date Incident Closed by CRC Incident Close Reason
20OCT2009 Abuser Refused treatment
SECTION VII - AUTHENTICATION
Date Incident Closed
by CRC AUTHENTICATING OFFICIAL SIGNATURE
23NOV2010 . Electonically Signed
