DD Form 2985-1 Military Feedback Form

Military Feedback Form

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If you have comments, compliments, or complaints about the services on your installation/base or provided by a Sexual Assault Response Coordinator (SARC), victim advocate or other military staff or personnel, please use this feedback form. You can submit the form anonymously if you prefer. Information you provide on this form will be forwarded to the DoD Sexual Assault Prevention and Response Office (SAPRO).

If you believe you have experienced or witnessed retaliation in any form from a peer, supervisor or someone in your chain of command following a report of sexual assault, you can report the retaliation allegations to SAPRO either anonymously or with your personal contact information. Reports of retaliation that are made to SAPRO will be forwarded to Department of Defense Inspector General (DoD IG) if your personal contact information is provided.

If you would like to submit a Whistleblower Reprisal retaliation report directly to the DoD IG click here. If you would like to report another type of retaliation or a general complaint to the DoD IG click here.

If you are a member of the Coast Guard, any report of retaliation made to SAPRO using this form that includes your personal contact information will be sent to the Coast Guard Investigative Service (CGIS) Washington Field Office (WFO). Or, if you would like to directly contact CGIS's WFO to make a report of retaliation, you can by calling 571-228-5414. Additionally, the Department of Homeland Security (DHS) IG will also accept retaliation complaints as falling within the scope of their responsibilities for Whistleblower protection. Call 1-800-323-8603 (toll free) or access the Allegation Form online.

Information you provide on this form will be forwarded to the DoD Sexual Assault Prevention and Response Office (SAPRO).

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* indicates a required field

First Name

Last Name

User 

*Please indicate which of the following applies to you

Service Affiliation 

*Please indicate which of the following applies to you

Status/Position 

*Please indicate which of the following applies to you

Installation/Base 

*Please tell us where the interaction took place

Date of Incident

Please give the date of the negative interaction (not the assault)

Name and/or Office of Military Personnel

Name and/or office of the person you are writing about

What is this person's title or position?

Your Comments 

*If you have a complaint, compliment, or believe you have experienced retaliation in any form, please be as specific as possible.

Would you like SAPRO to follow up with you regarding this complaint? *

If you answered yes, please provide your preferred contact information:

Email address

And/Or

Phone number

If you provided a phone number, is it ok to leave a message at this number?

 

 (case sensitive) 

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DD Form 2985-1

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 03F09, Alexandria, VA 22350-3100 (XXXX-XXXX)Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.

Privacy Act Statement

Authority: 10 U.S.C. 1561 note, Improved Sexual Assault Prevention and Response in the Armed Forces; DoD Directive 6495.01, Sexual Assault Prevention and Response (SAPR Program); DoD Instruction 6495.02, Sexual Assault Prevention and Response (SAPR) Program Procedures.

Principal Purpose(s): To track victim-related inquiries received by the Sexual Assault Prevention and Response Office (SAPRO) via e-mail, SAPR.mil, the DoD Safe Helpline, phone, or postal service. Once received, inquiries are referred to the appropriate agency POC and/or to the DoD IG in order to address the issue(s) raised and facilitate a resolution. To allow individuals to provide feedback on the services of a SARC, victim advocate, or other military staff or personnel on their installation/base. This form does not constitute a report of sexual assault.

The applicable system of Records Notices is DHRA XX, DoD Sexual Assault Prevention and Response Office Victim Assistance Data Systems at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/OSDJS-Article-List/

Routine Use(s): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. Applicable Blanket Routine Uses(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use. The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of DoD Blanket Routine Uses can be found online at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.

Disclosure: The completion of this form is voluntary. However, failure to provide information may result in the inability to provide requested services.