Form DD Form 2965 DD Form 2965 Defense Sexual Assault Incident Database (DSAID) Data Fo

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)
OMB No. 0704-0482
OMB approval expires
March 31, 2025

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM

The public reporting burden for this collection of information is estimated to average 2 hours 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, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. 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 MAIL, FAX, EMAIL OR STORE THIS FORM. DISPOSE OF COMPLETED FORM AS DIRECTED AT THE TOP OF EACH PAGE.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 8013, Secretary of the Navy; 10 U.S.C. 9013, Secretary
of the Air Force; 32 U.S.C. 102, National Guard; DoD Directive 6495.01, SAPR Program; DoD Instruction 6495.02, SAPR Program Procedures; Army Regulation 600-20, Chapter 7, Army
Command Policy (SAPR Program); OPNAV Instruction 1752.1C, SAPR Program; Marine Corps Order 1752.5C, SAPR Program; Air Force Instruction 90-6001, SAPR Program; and E.O. 9397
(SSN), as amended.
PRINCIPAL PURPOSE(S): To centralize case-level sexual assault data involving a member of the Armed Forces, in a manner consistent with statute and DoD regulations for Unrestricted and
Restricted reporting. To facilitate reports to Congress on claims of retaliation in connection with an Unrestricted Report of sexual assault made by or against a member of the Armed Forces.
Records may also be used as a management tool for statistical analysis, tracking, reporting, evaluating program effectiveness, conducting research, and case and business management. Deidentified data may also be used to respond to mandated reporting requirements. The DSAID File Locker, a separate module within the system, is used to maintain Victim Reporting Preference
Statements and DoD Sexual Assault Forensic Examinations (SAFEs) to ensure compliance with federal records retention requirements and allow Victims and reporters access to these forms for
potential use in Department of Veterans Affairs (DVA) benefits applications. https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DHRA-06-DoD.pdf
ROUTINE USE(S): Information provided may be further disclosed to the Department of Veterans Affairs (DVA) for benefits purposes and to facilitate collaborative research activities between the
DoD and DVA. In addition, this form is subject to the proper and necessary routine uses identified in the system of records notice(s) specified in the purpose statement above. In addition to those
disclosures generally permitted in accordance with 5 U.S.C. 552a(b), the records contained herein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as
follows:
a. To permit the disclosure of records of closed cases of Unrestricted Reports to the DVA for purpose of providing mental health and medical care to former Service members and retirees, to
determine the eligibility for or entitlement to benefits, and to facilitate collaborative research activities between the DoD and DVA. b. To contractors responsible for performing or working on
contracts for the DoD when necessary to accomplish an agency function related to this System of Records. Individuals provided information under this routine use are subject to the same Privacy
Act requirements and limitations on disclosure that apply to DoD officers and employees. c. To any component of the Department of Justice for the purpose of representing the DoD, or its
components, officers, employees, or members in pending or potential litigation to which the record is pertinent. d. In an appropriate proceeding before a court, grand jury, or administrative or
adjudicative body or official, when the DoD or other Agency representing the DoD determines that the records are relevant and necessary to the proceeding; or in an appropriate proceeding before
an administrative or adjudicative body when the adjudicator determines the records to be relevant to the proceeding. e. To the National Archives and Records Administration or the purpose of
records management inspections conducted under the authority of 44 U.S.C. 2904 and 2906. f. To a Member of Congress or staff acting upon the Member’s behalf when the Member or staff
requests the information on behalf of, and at the request of, the individual who is the subject of the record. g. To appropriate agencies, entities, and persons when (1) the DoD suspects or has
confirmed that there has been a breach of the System of Records; (2) the DoD has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, the DoD
(including its information systems, programs, and operations), the Federal Government, or national security; and (3) the disclosure made to such agencies, entities, and persons is reasonably
necessary to assist in connection with the DoD’s efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm. h. To another Federal agency or Federal
entity, when the DoD determines that information from this System of Records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach
or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems, programs and operations), the Federal Government, or
national security, resulting from a suspected or confirmed breach.
DISCLOSURE: Voluntary. However, if you decide not to provide certain information, it may impede the ability of the SARC to offer the full range of care and support established by the sexual
assault prevention and response program. You will not be denied benefits via the Restricted Reporting option. For Unrestricted Reports, the Social Security Number (SSN) is one of several unique
personal identifiers that may be provided. Some alternatives include state driver's license number, passport number, or DoD ID number.

HOW TO USE THIS FORM
Fields on this form should only be completed as needed to fulfill DSAID data requirements for the given type of report (Restricted or Unrestricted); that is, for Restricted Reports no personally
identifiable information for Victims (except for the Encryption Key information as described below) or subjects should be captured. In the event that a SARC does not have immediate access to
DSAID, this form may be used in the interim to capture the adult sexual assault Victim's information. The information captured on this form shall be entered in DSAID within the timeline established
in DoD Instruction (DoDI) 6495.02. In accordance with General Records Schedule (GRS) 5.2, 020, Intermediary Records, and the business use established in DoDI 6495.02, this form shall be
destroyed upon verification of successful creation of the information in DSAID or when no longer needed for business use, whichever is later. The form shall NOT be maintained longer than required
to input all information required into DSAID per the authorities above. Until such time as the form is destroyed, the form should be covered with a DD Form 2923, “Privacy Act Data Cover Sheet”,
and maintained under double-lock-and-key when not under the direct control of an individual with a need-to-know. For Restricted Reports, the data for the Encryption Key (see Section I, Block 4), is
necessary to maintain privacy and security of DD Forms 2910 and DD Form 2911 in a Restricted Report (RR). Any victim filing a RR may be asked to provide this information when his/her RR is
transferred or to access the forms stored electronically in the File Locker. For select definitions of terminology used below, please see the DSAID User Manual. This form cannot be used in place of
DD Forms 2910, 2910-1, or 2910-2 to officially report sexual assault, lost forms, and related retaliation, respectively.

SECTION I - DSAID CASE INFORMATION
1. DSAID CONTROL NUMBER

2. TYPE OF REPORT (X one)

RR-

RESTRICTED

UU-

UNRESTRICTED

4. ENCRYPTION KEYS (For Restricted Report only)
a. VICTIM DATE OF BIRTH
b. VICTIM MOTHER’S MAIDEN NAME
(MM/DD/YYYY)

3. SARC PRIMARY LOCATION (DSAID LOCATION CODE)

c. VICTIM STATE/COUNTRY OF BIRTH

b. DATE VICTIM SIGNED FORM ELECTING TO
CONVERT FROM RR TO RU (if applicable)
(MM/DD/YYYY)

5.a. AGE AT TIME OF INCIDENT

d. LAST 4 OF VICTIM SSN

c. RUd. CONVERSION REASON (If known or available)

6.a. DSAID CASE STATUS (X one)
OPEN

CLOSED

OPEN WITH LIMITED INFORMATION

b. EXPLANATION FOR OPEN WITH LIMITED INFORMATION STATUS (If applicable)
VICTIM REFUSED/DECLINED SERVICES
VICTIM OPT-OUT OF PARTICIPATING IN INVESTIGATIVE PROCESS
LOCAL JURISDICTION REFUSED TO PROVIDE VICTIM INFORMATION
CIVILIAN VICTIM WITH MILITARY SUBJECT
CIVILIAN VICTIM WITH CIVILIAN SUBJECT
FAMILY ADVOCACY PROGRAM
INDEPENDENT INVESTIGATION OR THIRD PARTY REPORT
INFORMATIONAL/I-TITLE FILE

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Controlled by: OUSD(P&R)
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil

Page 1 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
7. RESTRICTED REPORT REASON (X as applicable)
DESIRE TO AVOID RETELLING STORY
THOUGHT THE MATTER WAS NOT IMPORTANT ENOUGH TO REPORT TO LAW ENFORCEMENT
FEARED SOME KIND OF RETALIATION FROM OFFENDER OR THE OFFENDER’S FRIENDS
THOUGHT HE/SHE WOULD BE BLAMED/LABELED AS A TROUBLEMAKER
FEARED HE/SHE OR FRIENDS WOULD BE PUNISHED FOR A COLLATERAL OFFENSE, SUCH AS UNDERAGE DRINKING OR CURFEW VIOLATION
FEARED BEING THE TARGET OF GOSSIP OR HAVING REPUTATION DAMAGED IN THE EYES OF COMMANDER OR UNIT MEMBERS
THOUGHT HE/SHE WOULD NOT BE BELIEVED
WAS CONCERNED REPORTING WOULD PREVENT FINISHING TRAINING OR OPERATIONAL MISSION
WAS CONCERNED REPORTING WOULD DELAY RETURNING HOME FROM DEPLOYMENT
WAS CONCERNED THAT REPORTING WOULD RESULT IN BEING SENT HOME FROM A DEPLOYMENT EARLY
WAS CONCERNED REPORTING WOULD IMPACT SECURITY CLEARANCE
WAS CONCERNED REPORTING WOULD NEGATIVELY IMPACT CAREER
DID NOT WANT TO HURT ALLEGED OFFENDER’S CAREER
DID NOT WANT LAW ENFORCEMENT INVOLVEMENT
DID NOT WANT TO ENGAGE MILITARY JUSTICE SYSTEM
DECLINED TO SPECIFY REASON
OTHER

8. DATE OF REPORT TO DOD (MM/DD/YYYY)

9. RESTRICTED REPORT EXCEPTION APPLIED (X as applicable)

YES

NO

IF YES, REASON FOR EXCEPTION:

DISCLOSURE IS AUTHORIZED BY VICTIM IN WRITING.
DISCLOSURE IS NECESSARY TO PREVENT OR LESSEN A SERIOUS OR IMMINENT THREAT TO HEALTH OR SAFETY OF THE VICTIM OR ANOTHER
PERSON.
DISCLOSURE BY A HCP IS REQUIRED FOR FITNESS FOR DUTY FOR DISABILITY RETIREMENT DETERMINATIONS.
DISCLOSURE IS REQUIRED FOR SARC, VA, OR HCP TO PROVIDE SUPERVISION AND/OR COORDINATION OF DIRECT VICTIM TREATMENT OR SERVICES.
COMMUNICATE WHEN DISCLOSURE IS ORDERED BY A JUDGE, OR OTHER OFFICIALS OR ENTITIES AS REQUIRED BY A FEDERAL OR STATE STATUTE
OR APPLICABLE U.S. INTERNATIONAL AGREEMENT.

10. VICTIM NAME: a. LAST

b. FIRST

c. MIDDLE

11. ID TYPE (X one)
DOD ID NUMBER

SSN

PASSPORT NUMBER

ALIEN REGISTRATION

FOREIGN COUNTRY ID

UNKNOWN

ID NUMBER:

12.a. VA ASSIGNED (X one)
YES

b. IF YES, VA NAME:

c. IF NO, REASON:

NO

SECTION II - VICTIM INFORMATION (At time of Report, unless otherwise indicated)
13. DATE VICTIM INFORMED OF OPTIONS (MM/DD/YYYY)

14. DATE VICTIM SIGNED DD FORM 2910 (MM/DD/YYYY)

15. RELATIONSHIP TO SUBJECT(S) (X all that apply)
EMPLOYER

EMPLOYEE

COWORKER

SUPERVISOR/COMMAND

RECRUITER

NEIGHBOR

FRIEND

ACQUAINTANCE

STRANGER

INTIMATE PARTNER/DATING

SIBLING

SPOUSE

FORMER SPOUSE

ADULT CHILD

PARENT

EXTENDED FAMILY MEMBER

RELATIONSHIP UNKNOWN

OTHERWISE KNOWN

16.a. COMMANDER NAME

c. IF NO, REASON:
b. COMMAND NOTIFICATION
ACCOMPLISHED WITHIN 24
HOURS (X one)
YES

NO

17. INCIDENT OCCURRED: (X as applicable)
a. INCIDENT OCCURRED ON DEPLOYMENT?
YES

NO

18. DOES LOCATION REQUIRE MANDATORY
REPORTING FOR MEDICAL CARE FOR A
SEXUAL ASSAULT? (X one)
YES

b. INCIDENT OCCURRED ON TDY?
YES

NO

19. DATE OF BIRTH (MM/DD/YYYY)

c. INCIDENT OCCURRED ON LEAVE?
YES

NO

20. GENDER (X one)
MALE

FEMALE

NO

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Page 2 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
21. RACE AND ETHNICITY (Select All That Apply)
AMERICAN INDIAN OR ALASKA NATIVE (e.g., Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)
ASIAN (e.g., Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)
BLACK OR AFRICAN AMERICAN (e.g., African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)
HISPANIC OR LATINO (e.g., Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)
MIDDLE EASTERN OR NORTH AFRICAN (e.g., Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)
NATIVE HAWAIIAN OR PACIFIC ISLANDER (e.g., Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)
WHITE (e.g., English, German, Irish, Italian, Polish, Scottish, etc.)
CHOOSES NOT TO DISCLOSE
UNKNOWN

22. VICTIM TYPE (X one) (For adult dependents, select U.S. Civilian and complete Block 24, 26, 27, 28, and 29.)
MILITARY

DOD CIVILIAN

OTHER GOVT. CIVILIAN

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

DOD CONTRACTOR

23. VICTIM AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

COAST GUARD

DOD

NOAA

PUBLIC HEALTH

N/A

24. VICTIM STATUS
a. IF MILITARY, VICTIM DUTY STATUS (X one)
ACTIVE DUTY

b. VICTIM RECRUIT/TRAINING STATUS (X one)

NATIONAL GUARD (NG)

RESERVE

YES

c. (1) IF VICTIM DUTY STATUS IS NG, TYPE OF NATIONAL GUARD SERVICE (X one):

NO
TITLE 10

TITLE 32

(2) VICTIM NG STATE AFFILIATION (X one)
50 STATES (ENTER STATE):

(3) VICTIM NG TITLE 10 CATEGORY (X one)

DISTRICT OF COLUMBIA

PUERTO RICO

NATIONAL GUARD

ACTIVE DUTY ARMED SERVICES

GUAM

VIRGIN ISLANDS
RESERVISTS

(4) VICTIM NG TITLE 32 CATEGORY (X one)
STATE ACTIVE DUTY (SAD)

INACTIVE DUTY TRAINING (IDT)

ANNUAL TRAINING (AT)

NOT IN DUTY STATUS

TECHNICIAN/DUAL STATUS

TECHNICIAN/NON-DUAL STATUS

ACTIVE DUTY OPERATIONAL SUPPORT

ACTIVE GUARD AND RESERVE (AGR)

TRADITIONAL/M DAY

RECRUIT SUSTANMENT PROGRAM/STUDENT FLIGHT

PROFESSIONAL MILITARY EDUCATION

ROTC

(5) IF VICTIM IS TITLE 32 AND VICTIM RECRUIT/TRAINING STATUS IS YES, NG VICTIM RECRUIT/TRAINING STATUS (X one)
NG PRE-ACCESSION RECRUIT SUSTAINMENT PROGRAM (RSP)

PRE-RECRUIT GENERAL EDUCATION DEVELOPMENT (GED) PROGRAM

e. IF VICTIM IS MILITARY/CIVILIAN, PAY GRADE

d. IF VICTIM IS DOD CIVILIAN/OTHER GOVERNMENT CIVILIAN: PAY PLAN (X one)
GS

WG

NAF

SES

OTHER

f. VICTIM ASSIGNED LOCATION (i.e., Installation Name)

UNKNOWN

g. VICTIM ASSIGNED UIC

i. IF GUARD OR RESERVE, WAS LINE OF DUTY (LOD) INITIATED? (X one)

h. VICTIM ASSIGNED UNIT NAME

YES

NO

IF NO, X REASON:

VICTIM DID NOT WANT LOD INITIATED

NO INFORMATION AVAILABLE FROM ACTIVE DUTY SARC

ASSAULT DID NOT OCCUR IN DUTY STATUS

OTHER

LOD NOT OFFERED

25. VICTIM CONTACT INFORMATION (Address/Telephone/Email)

26. IF NOT MILITARY, VICTIM DEPENDENT STATUS (X one)
YES - MILITARY DEPENDENT

YES - DOD CIVILIAN (OCONUS) DEPENDENT

NO

27. VICTIM DEPENDENT RELATIONSHIP (X one)
SPOUSE

ADULT CHILD

PARENT

28. WAS THE VICTIM IN THE MILITARY AT THE TIME OF THE ASSAULT? (X one)

YES

NO

SECTION III - VICTIM SAFETY (For multiple instances, reuse as needed)
29.a. VICTIM SAFETY ASSESSMENT COMPLETED? (X and complete as applicable)

YES

NO

b. IF YES, WAS A VICTIM SAFETY CONCERN IDENTIFIED? (X one)
c. IF YES, VICTIM SAFETY CONCERN NOTE(S)

YES

NO

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Page 3 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
d. VICTIM SAFETY CONCERN NOTE DATE (MM/DD/YYYY)

e. IF A VICTIM SAFETY ASSESSMENT WAS NOT COMPLETED, WHAT WAS THE REASON?

f. VWAP (DD Form 2701) PROVIDED (X one)

30. VICTIM INFORMED OF RIGHT TO REQUEST EXPEDITED TRANSFER? (X one)

NO

YES

NO

b. IF YES, EFFECTIVE DATE OF CPO (MM/DD/YYYY)

YES

31.a. CIVILIAN PROTECTIVE ORDER (CPO) REQUESTED?
(X and complete as applicable)

YES

NO

YES
32.a. MILITARY PROTECTIVE ORDER (MPO) REQUESTED? (X and complete as applicable)
b. MPO REQUEST DATE
d. MPO ISSUE DATE
c. MPO ISSUED (X one)
e. MPO VIOLATED (X one)
(MM/DD/YYYY)
(MM/DD/YYYY)
YES
YES
NO

NO

IF YES:

f. IF YES, BY WHOM? (X one)
VICTIM

NO

SUBJECT

BOTH

g. IF MPO NOT ISSUED, WHY?
VICTIM SEPARATED FROM THE MILITARY/GOVT SERVICE/CONTRACT
VICTIM CHANGED DUTY LOCATIONS
VICTIM IN CONFINEMENT
VICTIM DIED
ALLEGED SUBJECT SEPARATED FROM THE MILITARY/GOVT SERVICE/CONTRACT
ALLEGED SUBJECT BARRED FROM ENTERING THE INSTALLATION
ALLEGED SUBJECT IN CONFINEMENT
ALLEGED SUBJECT DIED
NO CONTACT ORDER ISSUED INSTEAD
OTHER, REASON:
33. VICTIM EXPEDITED TRANSFER
a. DATE VICTIM REQUESTED EXPEDITED TRANSFER (MM/DD/YYYY)

b. VICTIM EXPEDITED TRANSFER REQUESTED TYPE (X one)
LOCAL - UNIT/DUTY TRANSFER

c. COMMAND DECISION FOR EXPEDITED TRANSFER (X one)

APPROVE

PCS - INSTALLATION TRANSFER

DISAPPROVE

d. REASON FOR DISAPPROVED EXPEDITED TRANSFER PER COMMAND DECISION (X one)
NO CREDIBLE REPORT DETERMINATION OF A SEXUAL ASSAULT
MOVED ALLEGED OFFENDER INSTEAD
ALLEGED OFFENDER IS NO LONGER ASSIGNED TO THE COMMAND OR BASE
VICTIM HAS A PRE-EXISTING TRANSFER ORDER (e.g., PCS)
VICTIM DECLINED TO PARTICIPATE IN AN MCIO INVESTIGATION
VICTIM IS A SUBJECT OF A SEPARATE CRIMINAL INVESTIGATION
VICTIM RESCINDED THE REQUEST
VICTIM IS PENDING UCMJ ACTION
VICTIM IS PENDING SEPARATION
VICTIM IS PENDING A MEDICAL EVALUATION BOARD
OTHER, EXPLAIN:
e. DATE OF COMMAND DECISION FOR EXPEDITED TRANSFER
(MM/DD/YYYY)

f. VICTIM TRANSFERRED PER COMMAND DECISION? (X one)
YES

g. VICTIM REQUESTED REVIEW FOR EXPEDITED TRANSFER? (X one)
YES

NO

h. SENIOR LEVEL DECISION FOR EXPEDITED TRANSFER? (X one)
APPROVE

i. DATE OF SENIOR LEVEL DECISION FOR EXPEDITED TRANSFER
(MM/DD/YYYY)

NO

DISAPPROVE

j. VICTIM TRANSFERRED PER SENIOR LEVEL COMMAND DECISION?
(X one)
YES

NO

k. DATE OF VICTIM’S PERMANENT CHANGE OF STATION/PERMANENT CHANGE OF ASSIGNMENT (MM/DD/YYYY)

l. HAS THE SARC OUT BRIEF MEETING OCCURRED? (X one)
YES

NO

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

UNKNOWN

m. HAS THE SARC INTAKE MEETING BEEN SCHEDULED? (X one)
YES

CUI (when filled in)

NO

UNKNOWN

Page 4 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION IV - REFERRAL SUPPORT (For multiple instances, reuse as needed)
34.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

BEHAVIORAL HEALTH

CHAPLAIN/SPIRITUAL SUPPORT

RAPE CRISIS CENTER

DOD SAFE HELPLINE

OTHER, EXPLAIN:

LEGAL/SPECIAL VICTIMS’
COUNSEL (SVC)
VICTIM ADVOCATE/UNIFORMED
VICTIM ADVOCATE

c. DATE OF REFERRAL
(MM/DD/YYYY)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

35.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

BEHAVIORAL HEALTH

CHAPLAIN/SPIRITUAL SUPPORT

RAPE CRISIS CENTER

DOD SAFE HELPLINE

OTHER, EXPLAIN:

LEGAL/SPECIAL VICTIMS’
COUNSEL (SVC)
VICTIM ADVOCATE/UNIFORMED
VICTIM ADVOCATE

c. DATE OF REFERRAL
(MM/DD/YYYY)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

36.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

BEHAVIORAL HEALTH

CHAPLAIN/SPIRITUAL SUPPORT

RAPE CRISIS CENTER

DOD SAFE HELPLINE

OTHER, EXPLAIN:

LEGAL/SPECIAL VICTIMS’
COUNSEL (SVC)
VICTIM ADVOCATE/UNIFORMED
VICTIM ADVOCATE

c. DATE OF REFERRAL
(MM/DD/YYYY)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

37.a. REFERRAL RESOURCE TYPE (X one)

MILITARY

CIVILIAN

b. TYPE OF SUPPORT (X all that apply)
MEDICAL

BEHAVIORAL HEALTH

CHAPLAIN/SPIRITUAL SUPPORT

RAPE CRISIS CENTER

DOD SAFE HELPLINE

OTHER, EXPLAIN:

LEGAL/SPECIAL VICTIMS’
COUNSEL (SVC)
VICTIM ADVOCATE/UNIFORMED
VICTIM ADVOCATE

c. DATE OF REFERRAL
(MM/DD/YYYY)

d. REFERRAL SERVICE COMMENT (NOTE: Do NOT enter any HIPAA information.)

SECTION V - FORENSIC EXAM
38. WAS FORENSIC EXAM OFFERED? (X one)
IF NO, REASON:

YES

NO

YES
NO
39.a. WAS FORENSIC EXAM COMPLETED? (X and complete as applicable)
(2) DATE OF EXAM (MM/DD/YYYY) c. IF NO, WAS IT BECAUSE SAFE KIT AND/OR
b. IF YES: (1) LOCATION OF FORENSIC EXAM:
OTHER NEEDED SUPPLIES NOT AVAILABLE?
ON INSTALLATION
OFF INSTALLATION

YES
NO

(3) STORAGE LOCATION OF SAFE KIT

40. RESTRICTED REPORT CONTROL NUMBER (For Restricted Report only)

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Page 5 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
SECTION VI - INVESTIGATIVE AGENCY
41.a. INVESTIGATIVE CASE FILE OPENED: (X and complete as applicable)
b. IF YES, INVESTIGATIVE CASE NUMBER*

YES

NO

c. INITIAL INVESTIGATIVE AGENCY LOCATION

*REFER TO THE DSAID SUPPORT PAGE FOR CURRENT INVESTIGATIVE CASE NUMBER FORMATS.
d. IF NO, PROVIDE A REASON (X and complete as applicable)
INCIDENT OCCURRED PRIOR TO VICTIM'S MILITARY SERVICE
INCIDENT BEYOND STATUTE OF LIMITATIONS

ALLEGED PERPETRATOR NOT SUBJECT TO UCMJ

OTHER (Specify)

42. AGENCY CONDUCTING INVESTIGATION (X one)
NCIS

AFOSI

ARMY CID

NG/JA/OCI

CGIS

CIVILIAN LAW ENFORCEMENT

43. DATE INVESTIGATIVE ACTIVITY OPENED 44. INVESTIGATIVE ACTIVITY COMPLETED (X and complete as applicable)
(MM/DD/YYYY)
IF YES, DATE INVESTIGATIVE ACTIVITY COMPLETED (MM/DD/YYYY)
YES

NO

SECTION VII - INVESTIGATIVE AGENCY CASE TRANSFER (If applicable)
46. ASSOCIATED INVESTIGATIVE CASE NUMBER (See format instructions above)

45. INVESTIGATIVE AGENCY CASE TRANSFERRED (X one)
ACROSS SERVICES

WITHIN SERVICES

TO NON-MILITARY JURISDICTION

47. INVESTIGATIVE AGENCY CASE
TRANSFER DATE (MM/DD/YYYY)

48. AGENCY CONDUCTING INVESTIGATION (X one)
NCIS

AFOSI

ARMY CID

NG/JA/OCI

CGIS

CIVILIAN LAW ENFORCEMENT

49. GAINING INVESTIGATIVE AGENCY LOCATION

SECTION VIII - SUBJECT INFORMATION (For multiple subjects, reuse as needed.)
50. RESTRICTED REPORT: SUBJECT TYPE (X one)
MILITARY - CADET/MIDSHIPMAN/PREP SCHOOL STUDENT
OTHER GOVT. CIVILIAN

U.S. CIVILIAN

MILITARY - NON CADET/MIDSHIPMAN/PREP SCHOOL STUDENT

FOREIGN NATIONAL

UNRESTRICTED REPORT:
51. SUBJECT NAME: a. LAST

FOREIGN MILITARY

b. FIRST

SSN

UNKNOWN

c. MIDDLE

52. ID TYPE (X one)
DOD ID NUMBER

DOD CONTRACTOR

DOD CIVILIAN

PASSPORT NUMBER

ALIEN REGISTRATION

53. DATE OF BIRTH
(MM/DD/YYYY)

54. AGE AT TIME OF 55. GENDER (X one)
INCIDENT
MALE
FEMALE

FOREIGN COUNTRY ID

UNKNOWN ID NUMBER:

UNKNOWN

56. RACE AND ETHNICITY (Select All That Apply)
AMERICAN INDIAN OR ALASKA NATIVE (e.g., Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)
ASIAN (e.g., Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)
BLACK OR AFRICAN AMERICAN (e.g., African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)
HISPANIC OR LATINO (e.g., Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)
MIDDLE EASTERN OR NORTH AFRICAN (e.g., Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)
NATIVE HAWAIIAN OR PACIFIC ISLANDER (e.g., Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)
WHITE (e.g., English, German, Irish, Italian, Polish, Scottish, etc.)
CHOOSES NOT TO DISCLOSE
UNKNOWN

57. DEPENDENT STATUS (X one)

YES

NO

58. SUBJECT TYPE (X one)
MILITARY

DOD CIVILIAN

OTHER GOVERNMENT CIVILIAN

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

DOD CONTRACTOR

UNKNOWN

59. SERVICE AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

MARINE CORPS

SPACE FORCE

COAST GUARD

CUI (when filled in)

DOD

NOAA

PUBLIC HEALTH

UNKNOWN

Page 6 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
60.a. DUTY STATUS (X one if applicable)
ACTIVE DUTY

NATIONAL GUARD (NG)

RESERVE

UNKNOWN

b. IF SUBJECT DUTY STATUS IS NG:
(1) SUBJECT NATIONAL GUARD SERVICE (X one)

(2) SUBJECT NG STATE AFFILIATION (X one)

TITLE 10

50 STATES (ENTER STATE):

TITLE 32

PUERTO RICO

(3) SUBJECT NG TITLE 10 CATEGORY (X one)

DISTRICT OF COLUMBIA
GUAM

ACTIVE GUARD AND RESERVE (AGR)

VIRGIN ISLANDS

ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)

ANNUAL TRAINING (AT)

ACTIVE DUTY ARMED SERVICES

BASIC TRAINING

MOBILIZED OCONUS

MOBILIZED CONUS

PROFESSIONAL MILITARY EDUCATION (PME)

(4) SUBJECT NG TITLE 32 CATEGORY (X one)

ACTIVE GUARD AND RESERVE (AGR)

ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)
ROTC

STATE ACTIVE DUTY (SAD)

TECHNICAL/ADVANCED INDIVIDUAL TRAINING (AIT)

ANNUAL TRAINING (AT)

PROFESSIONAL MILITARY EDUCATION (PME)

NOT IN DUTY STATUS

RESERVISTS
INACTIVE DUTY TRAINING (IDT)

RECRUIT SUSTAINMENT PROGRAM/STUDENT FLIGHT

TECHNICIAN DUAL STATUS

TECHNICIAN NON DUAL STATUS

(5) NG SUBJECT RECRUIT/TRAINING STATUS (X one)
NG PRE-ACCESSION RECRUIT SUSTAINMENT PROGRAM (RSP)

c. IF SUBJECT IS MILITARY/CIVILIAN, PAY GRADE

PRE-RECRUIT GENERAL EDUCATION DEVELOPMENT (GED) PROGRAM

N/A

d. SUBJECT DUTY ASSIGNMENT (X one)
RECRUITER

INSTRUCTOR

DRILL SERGEANT

DRILL INSTRUCTOR

MEPS (MILITARY ENTRANCE PROCESSING STATION)

N/A

e. IF SUBJECT IS DOD CIVILIAN/OTHER GOVERNMENT CIVILIAN: PAY PLAN (X one)
GS

WG

NAF

SES

OTHER

UNKNOWN

g. SUBJECT ASSIGNED UNIT NAME

f. SUBJECT ASSIGNED LOCATION (i.e., Installation Name)

h. SUBJECT ASSIGNED UIC

SECTION IX - INCIDENT DETAIL
61.a. FOR RESTRICTED REPORT, IS DATE OF INCIDENT KNOWN (X and complete as applicable)
b. IF YES, DATE OF INCIDENT (MM/DD/YYYY)

YES

62. FOR UNRESTRICTED REPORT:
a. DATE OF INCIDENT (MM/DD/YYYY)

YES

NO

c. IS DATE AN ESTIMATE? (X one)
NO

b. IS DATE AN ESTIMATE? (X one)
YES

NO

63. INCIDENT TIME OF DAY
MIDNIGHT TO 6 AM

6 AM TO 6 PM

6 PM TO MIDNIGHT

UNKNOWN

64.a. INCIDENT LOCATION (X one)
ON MILITARY INSTALLATION/SHIP (OTHER THAN ACADEMY GROUNDS)

ON ACADEMY GROUNDS

OFF MILITARY INSTALLATION/SHIP/ACADEMY GROUNDS

UNIDENTIFIED

b. TYPE OF LOCATION (X all that apply)
MULTIPLE LOCATIONS

UNKNOWN

SUBMARINE
BANK/SAVING AND LOAN (includes other financial institutions, credit
union)
CHURCH/SYNAGOGUE/TEMPLE (includes religious buildings)

AIR/BUS/TRAIN TERMINAL
BAR/NIGHT CLUB/OFFICER CLUB/NONCOMMISSIONED OFFICER
CLUB
COMMERCIAL/OFFICE BUILDING

CONSTRUCTION SITE

FIELD/WOODS, TRAINING AREA

CONVENIENCE STORE, SHOPPETTE
DRUG STORE/DOCTOR’S OFFICE/HOSPITAL, CLINIC (includes medical
supply building)
GOVERNMENT/PUBLIC BUILDING

GROCERY/SUPERMARKET, COMMISSARY

HIGHWAY/ROAD/ALLEY (includes street)

HOTEL/MOTEL/ETC. (includes other temporary military lodging)

JAIL/PRISON/CORRECTIONS FACILITY (includes penitentiary)

LAKE/WATERWAY/OCEAN

RESIDENCE/HOME

LIQUOR STORE, CLASS VI
RENTAL STORAGE FACILITY (includes “Mini-Storage” and “Self-Storage
buildings)
RESTAURANT, DINING FACILITY (includes cafeteria)

SCHOOL/COLLEGE (includes university)

SERVICE/GAS STATION

CONCESSIONAIRRE/SPECIALTY STORY

CHILD CARE CENTER

RECREATION AREA/PARK

TRAINING CENTER/SERVICE SCHOOL

ON BOARD SHIP

AIRCRAFT

DEPARTMENT/DISCOUNT STORE, EXCHANGE

PARKING LOT/GARAGE, MOTOR POOL

PRIVATE VEHICLE
c. HOUSING TYPE
BARRACKS

BEQ

OTHER

UNKNOWN

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

BOQ

CUI (when filled in)

QUARTERS/FAMILY HOUSING
Page 7 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
d. INCIDENT LOCATION NAME

e. STATE/COUNTRY

f. CITY

65. FOR VICTIM AND/OR SUBJECT: (X as applicable)
a. WAS ALCOHOL INVOLVED?

YES

66. WEAPONS USED? (X as applicable)

NO

UNKNOWN

YES

NO

b. WERE DRUGS INVOLVED?

YES

NO

UNKNOWN

UNKNOWN

67. TYPE(S) OF OFFENSE INVESTIGATED
a. FOR INCIDENTS OCCURRED PRIOR TO OCTOBER 1, 2007: (X as applicable)
RAPE (ART. 120)

INDECENT ASSAULT (ART. 134)

FORCIBLE SODOMY (ART. 125)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

UNKNOWN (NG ONLY)

PROSECUTED BY STATE LAW (NG ONLY)

b. FOR INCIDENTS OCCURRED ON OR AFTER OCTOBER 1, 2007 AND BEFORE JUNE 28, 2012: (X as applicable)
RAPE (ART. 120)

AGGRAVATED SEXUAL ASSAULT (ART. 120)

WRONGFUL SEXUAL CONTACT (ART. 120)
UNKNOWN (NG ONLY)

AGGRAVATED SEXUAL CONTACT (ART. 120)

FORCIBLE SODOMY (ART. 125)

ABUSIVE SEXUAL CONTACT (ART. 120)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

INDECENT ASSAULT (ART.134)

PROSECUTED BY STATE LAW (NG ONLY)

c. FOR INCIDENTS OCCURRED ON OR AFTER JUNE 28, 2012 AND BEFORE JANUARY 1, 2019: (X as applicable)
RAPE (ART. 120)

SEXUAL ASSAULT (ART. 120)

FORCIBLE SODOMY (ART. 125)

AGGRAVATED SEXUAL CONTACT (ART. 120)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

ABUSIVE SEXUAL CONTACT (ART. 120)

UNKNOWN (NG ONLY)

PROSECUTED BY STATE LAW (NG ONLY)

d. FOR INCIDENTS OCCURRED ON OR AFTER JANUARY 1, 2019: (X as applicable)
RAPE (ART. 120)

SEXUAL ASSAULT (ART. 120)

ATTEMPTS TO COMMIT OFFENSES (ART. 80)

AGGRAVATED SEXUAL CONTACT (ART. 120)

UNKNOWN (NG ONLY)

ABUSIVE SEXUAL CONTACT (ART. 120)

PROSECUTED BY STATE LAW (NG ONLY)

e. IF VICTIM DUTY STATUS WAS NG AT THE TIME OF INCIDENT:
(1) PAY GRADE AT TIME OF INCIDENT
(2) VICTIM NATIONAL GUARD SERVICE AT TIME OF INCIDENT (X one)
TITLE 10

TITLE 32

(3) VICTIM NG TITLE 10 CATEGORY AT THE TIME OF INCIDENT (X one)
BASIC TRAINING

TECHNICAL/ADVANCED INDIVIDUAL TRAINING (AIT)

MOBILIZED OCONUS

MOBILIZED CONUS

ANNUAL TRAINING (AT)

ACTIVE DUTY ARMED SERVICES

ACTIVE GUARD AND RESERVE (AGR)

PROFESSIONAL MILITARY EDUCATION (PME)

ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)

(4) VICTIM NG TITLE 32 CATEGORY AT THE TIME OF INCIDENT (X one)
STATE ACTIVE DUTY (SAD)

INACTIVE DUTY TRAINING (IDT)

ANNUAL TRAINING (AT)

TECHNICIAN DUAL STATUS

TECHNICIAN NON-DUAL STATUS

RECRUIT SUSTAINMENT PROGRAM/STUDENT FLIGHT

PROFESSIONAL MILITARY EDUCATION (PME)

ROTC

ACTIVE GUARD AND RESERVE (AGR)

NOT IN DUTY STATUS
ACTIVE DUTY OPERATIONAL SUPPORT (ADOS)

(5) NG VICTIM RECRUIT/TRAINING STATUS
NG PRE-ACCESSION RECRUIT SUSTAINMENT PROGRAM (RSP)

PRE-RECRUIT GENERAL EDUCATION DEVELOPMENT (GED) PROGRAM

SECTION X – SEXUAL ASSAULT RELATED RETALIATION CASE INFORMATION
68. RETALIATION CONTROL NUMBER

69. ASSOCIATED DSAID CONTROL NUMBER

70. INVOLVES MULTIPLE DSAID CASES? (X one)
YES

71. SARC PRIMARY LOCATION (DSAID LOCATION CODE)

73. DSAID RETALIATION CASE STATUS (X one)
OPEN

NO

72. DATE ALLEGATIONS OF RETALIATION WAS REPORTED (MM/DD/YYYY)

74. TYPE OF RETALIATION REPORTER (X one)

CLOSED

ADULT SEXUAL ASSAULT VICTIM

VICTIM'S FAMILY MEMBER

WITNESS

BYSTANDER (WHO INTERVENED)

SARC ON THIS CASE

RESPONDER

SAPR VA ON THIS CASE

OTHER PARTY

75. INDIVIDUAL/ORGANIZATION TO WHOM THE REPORT OF RETALIATION WAS MADE (X one)
ARMY IG

AIR FORCE IG

ARMY CHAIN OF COMMAND

NAVY IG

USMC CHAIN OF COMMAND
AFOSI

CGIS

COAST GUARD IG

ARMY LAW ENFORCEMENT

NATIONAL GUARD IG

DOD IG

NATIONAL GUARD CHAIN OF COMMAND

COAST GUARD CHAIN OF COMMAND

NG OCI

MARINE CORPS LAW ENFORCEMENT
NON-DOD ENTITY

USMC IG

AIR FORCE CHAIN OF COMMAND

SPACE FORCE CHAIN OF COMMAND

AIR FORCE LAW ENFORCEMENT

COAST GUARD LAW ENFORCEMENT

SARC

SPACE FORCE IG

NAVY CHAIN OF COMMAND
ARMY CID

NCIS

NAVY LAW ENFORCEMENT

SAPR VA

MEO ADVISOR/REPRESENTATIVE

OTHER

76. OTHER INDIVIDUAL/ORGANIZATION TO WHOM THE REPORT OF RETALIATION WAS MADE

77. RETALIATION REPORTER NAME: a. LAST

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

b. FIRST

c. MIDDLE

CUI (when filled in)

Page 8 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

DEFENSE SEXUAL ASSAULT INCIDENT DATABASE (DSAID) DATA FORM
78. REPORTER IDENTIFICATION TYPE (X one)
DOD ID NUMBER

PASSPORT NUMBER

ALIEN REGISTRATION NUMBER

FOREIGN COUNTRY ID

UNKNOWN

ID NUMBER:

79. REPORTER DATE OF BIRTH (MM/DD/YYYY)

80. REPORTER GENDER (X one)
MALE

FEMALE

81. DATE THAT THE RETALIATION REPORTER WAS INFORMED OF THE TYPES OF INVESTIGATIVE ENTITIES, TO INCLUDE THE IG, AND THE
AVAILABILITY OF SVC/VLC (IF ELIGIBLE) (MM/DD/YYYY)

82. RETALIATION REPORTER AGREED TO HAVE THEIR CASE DISCUSSED AT CMG (X one)

YES

NO

83. PRIVACY ISSUES PREVENT SARC FROM DISCUSSING REPORTING ENTITIES WITH THE REPORTER (X one)

YES

NO

84. NARRATIVE OF THE RETALIATION ALLEGATION(S)

85. REPORTER TYPE (X one)
MILITARY

DOD CIVILIAN

DOD CONTRACTOR

OTHER GOVERNMENT CIVILIAN

U.S. CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

UNKNOWN (SERVICE/DOD IG)

86. SERVICE AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

SPACE FORCE

COAST GUARD

DOD

NOAA

PUBLIC HEALTH

N/A

87.a. DUTY STATUS (X one, if applicable)
ACTIVE DUTY

NATIONAL GUARD (NG)

RESERVE

b. IF REPORTER DUTY STATUS IS NG:
(1) REPORTER NATIONAL GUARD SERVICE (X one)

(2) REPORTER PAY PLAN (X one)

TITLE 10
TITLE 32

(5) REPORTER ASSIGNED LOCATION

GS

WG

NAF

SES

OTHER

UNKNOWN

(3) REPORTER PAY GRADE

(6) REPORTER ASSIGNED UNIT NAME

88. IS SUPPORT BEING PROVIDED TO THE REPORTER? (X one)

YES

(4) REPORTER GRADE

(7) REPORTER ASSIGNED UIC

NO

89. ACTIONS TAKEN TO SUPPORT REPORTER OF RETALIATION (X all that apply)
BRIEFING/TRAINING FOR UNIT/INSTALLATION
UNFAVORABLE PERSONNEL ACTION, PUNISHMENT, OR ADMINISTRATIVE ACTION AGAINST THE RETALIATION REPORTER REVERSED
COMMAND IMPLEMENTED NEW POLICIES
TRANSFER OF RETALIATION REPORTER
MILITARY PROTECTIVE ORDER ISSUED OR CIVILIAN PROTECTIVE ORDER OBTAINED BY RETALIATION REPORTER
SAFETY PLAN UPDATED FOR RETALIATION REPORTER
COMMAND TOOK ACTION ON BEHALF OF THE RETALIATION REPORTER TO END THE NEGATIVE TREATMENT
COMMAND IS MONITORING THE SITUATION
COMMAND IS PROVIDING DIRECT SUPPORT TO THE REPORTER
ACTION PENDING
NO ACTION TAKEN
OTHER
UNKNOWN

90. OTHER ACTIONS TAKEN TO SUPPORT REPORTER OF RETALIATION

91. REASON NO SUPPORT IS BEING PROVIDED (X one)
ALLEGATIONS UNSUBSTANTIATED BASED ON ADMINISTRATIVE INVESTIGATIONS

REPORTER LEFT SERVICE

ALLEGATIONS UNFOUNDED BASED ON CRIMINAL INVESTIGATIONS ONLY, PER DODI 5505.18

REPORTER DID NOT WANT ANY ACTION TAKEN

NO OFFICIAL COMPLAINT/COMPLAINT WITHDRAWN

REPORTER DIED/DESERTED

COMMAND DECLINED ACTION

OTHER

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Page 9 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

92. OTHER REASON NO SUPPORT IS BEING PROVIDED

CUI (when filled in)

93. REPORTER SUPPORT CASE NOTES

94. INVESTIGATION CASE FILE OPENED (X one)

YES

NO

95. REASON WHY NO INVESTIGATION OPENED (X one)
DID NOT MEET THE THRESHOLD FOR RETALIATION (I.E., REPRISAL ACTIONS, RESTRICTION, OSTRACISM, CRUELTY OR MALTREATMENT, OR CRIMINAL
ACT FOR A RETALIATORY PURPOSE)
REFERRED TO ANOTHER AGENCY TO INVESTIGATE (E.G., DOD IG)
REPORTER DIED

REPORTER DECLINED TO PARTICIPATE IN THE INVESTIGATION

REPORTER WITHDREW COMPLAINT

REPORTER IS ABSENT WITHOUT LEAVE

REPORTER SEPARATED FROM THE SERVICE

96. PROGRAM RESPONSIBLE FOR INVESTIGATING RETALIATION ALLEGATION(S) (X one)
ARMY IG

AIR FORCE IG

NAVY IG

USMC IG

COAST GUARD IG

ARMY CHAIN OF COMMAND

AIR FORCE CHAIN OF COMMAND

USMC CHAIN OF COMMAND

COAST GUARD CHAIN OF COMMAND

AFOSI

CGIS

NG OCI

MARINE CORPS LAW ENFORCEMENT

AIR FORCE LAW ENFORCEMENT

ARMY CID

NCIS

NAVY LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE (ARMY)

MEO ADVISOR/REPRESENTATIVE (NAVY)

MEO ADVISOR/REPRESENTATIVE (MARINES)

MEO ADVISOR/REPRESENTATIVE (NATIONAL GUARD)

97. INVESTIGATIVE CASE NUMBER

SPACE FORCE IG

NAVY CHAIN OF COMMAND

SPACE FORCE CHAIN OF COMMAND

COAST GUARD LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE (COAST GUARD)

DOD IG

NATIONAL GUARD CHAIN OF COMMAND

ARMY LAW ENFORCEMENT

MEO ADVISOR/REPRESENTATIVE (AIR FORCE)

NATIONAL GUARD IG

NON-DOD ENTITY

98. DEFENSE CASE ACTIVITY TRACKING SYSTEM (IG) CASE NUMBER

99. DATE INVESTIGATIVE ACTIVITY OPENED (MM/DD/YYYY)

100. INVESTIGATIVE ACTIVITY COMPLETED? (X one)
YES

101. DATE INVESTIGATIVE ACTIVITY COMPLETED (MM/DD/YYYY)

NO

102. RESULTS OF THE INVESTIGATION PROVIDED TO RETALIATION
REPORTER? (X one)
YES, RESULTS PROVIDED TO THE REPORTER
NO, RESULTS NOT PROVIDED TO THE REPORTER

103. IF NO, REASON (RESULTS OF THE INVESTIGATION NOT PROVIDED TO RETALIATION REPORTER) (X one)
REPORTER SEPARATED FROM THE SERVICE

REPORTER IS ABSENT WITHOUT LEAVE

REPORTER DIED

OTHER

104. IF NO, OTHER REASON (WHY RESULTS OF THE INVESTIGATION NOT PROVIDED TO RETALIATION REPORTER)

105. IS RETALIATOR KNOWN? (X one)

YES

NO

106. RETALIATOR TYPE (X one)

107. RETALIATOR NAME
MILITARY

a. LAST

DOD CIVILIAN

DOD CONTRACTOR

OTHER GOVERNMENT CIVILIAN

b. FIRST
U.S. CIVILIAN

c. MIDDLE

FOREIGN NATIONAL

FOREIGN MILITARY

UNKNOWN

108. IS DOD ID NUMBER AVAILABLE? (X one) 109. IF YES, RETALIATOR DOD IDENTIFICATION NUMBER 110. RETALIATOR GENDER (X one)
YES

NO

MALE

FEMALE

111. RETALIATOR AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

MARINE CORPS

112. RETALIATOR DUTY STATUS (X one)
ACTIVE DUTY

RESERVE

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

COAST GUARD

DOD

NOAA

PUBLIC HEALTH

N/A

113. RETALIATOR DUTY ASSIGNMENT (X one)

NATIONAL GUARD (NG)

114. RETALIATOR NATIONAL GUARD SERVICE (X one)
TITLE 10

SPACE FORCE

RECRUITER

INSTRUCTOR

DRILL SERGEANT

MEPS (MILITARY ENTRANCE PROCESSING STATION)

DRILL INSTRUCTOR
N/A

115. RETALIATOR PAY GRADE AT TIME OF INCIDENT

TITLE 32

CUI (when filled in)

Page 10 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

116. RELATIONSHIP BETWEEN ALLEGED RETALIATOR(S) AND RETALIATION REPORTER (X one)
ALLEGED RETALIATOR(S) IS A SUPERIOR IN THE CHAIN OF COMMAND OF THE REPORTER
ALLEGED RETALIATOR(S) IS A SUPERIOR NOT IN THE CHAIN OF COMMAND OF THE REPORTER
ALLEGED RETALIATOR(S) IS JUNIOR IN GRADE TO REPORTER (IN OR OUTSIDE OF THE CHAIN OF COMMAND)
ALLEGED RETALIATOR(S) IS A PEER, CO-WORKER, FRIEND, OR FAMILY MEMBER OF THE RETALIATION REPORTER
ALLEGED RETALIATOR(S) IS ASSOCIATED WITH ALLEGED PERPETRATOR OF SEXUAL ASSAULT
ALLEGED RETALIATOR(S) IS A SERVICE PROVIDER OR OTHER OFFICIAL INVOLVED IN THE REPORT
ALLEGED RETALIATOR(S) RELATIONSHIP IS UNKNOWN OR INVESTIGATION ONGOING
ALLEGED RETALIATOR(S) IS THE ALLEGED PERPETRATOR OF SEXUAL ASSAULT

117. RELATIONSHIP BETWEEN ALLEGED RETALIATOR AND ALLEGED PERPETRATOR OF SEXUAL ASSAULT (X one)
ALLEGED RETALIATOR(S) IS ALSO THE ALLEGED PERPETRATOR OF SEXUAL ASSAULT
ALLEGED RETALIATOR(S) IS A SUPERIOR OF THE ALLEGED PERPETRATOR (IN OR OUTSIDE CHAIN OF COMMAND)
ALLEGED RETALIATOR(S) IS JUNIOR IN GRADE TO THE ALLEGED PERPETRATOR (IN OR OUTSIDE CHAIN OF COMMAND)
ALLEGED RETALIATOR(S) IS A PEER, CO-WORKER, FRIEND, OR FAMILY MEMBER OF THE ALLEGED PERPETRATOR
ALLEGED RETALIATOR(S) AND ALLEGED PERPETRATOR HAVE NO DIRECT ASSOCIATION
ALLEGED RETALIATOR(S) RELATIONSHIP IS UNKNOWN/INVESTIGATION ONGOING
ALLEGED PERPETRATOR(S) RELATIONSHIP IS UNKNOWN/INVESTIGATION ONGOING

SECTION XI – SAPR-RELATED INQUIRY (SRI)
119. DATE OF INQUIRY (MM/DD/YYYY)

118. SRI CONTROL NUMBER

120. SARC LOCATION CODE

SI121. SARC NAME

122. SARC AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

SPACE FORCE

MARINE CORPS

COAST GUARD

NATIONAL GUARD

DOD

NOAA

PUBLIC HEALTH

123. TYPE OF INQUIRER (X all that apply)
CHOOSES NOT TO DISCLOSE

VICTIM (SELF)

NEIGHBOR

ACQUAINTANCE

LOVE INTEREST/DATING

EXTENDED FAMILY MEMBER

EMPLOYEE

EMPLOYER

STRANGER

OTHERWISE KNOWN

RELATIONSHIP UNKNOWN

SUPERVISOR/COMMAND

RECRUITER

COWORKER

124. VICTIM GENDER (X one)
MALE

125. VICTIM TYPE (X one)

FEMALE

MILITARY

DOD CIVILIAN

DOD CONTRACTOR

OTHER GOVERNMENT CIVILIAN

FOREIGN NATIONAL

FOREIGN MILITARY

126. VICTIM AFFILIATION (X one)
ARMY

NAVY

AIR FORCE

SPACE FORCE

MARINE CORPS

COAST GUARD

NATIONAL GUARD

DOD

NOAA

PUBLIC HEALTH

127. VICTIM PERSONNEL TYPE (X one)
OFFICER

ENLISTED

ACADEMY CADET/MIDSHIPMAN

128. REASON FOR NOT REPORTING (X all that apply)
WANTED TO FORGET ABOUT IT AND MOVE ON
DID NOT WANT MORE PEOPLE TO KNOW
FELT ASHAMED OR EMBARRASSED
FELT PARTIALLY TO BLAME
THOUGHT IT WAS NOT SERIOUS ENOUGH TO REPORT
DID NOT THINK ANYTHING WOULD BE DONE
WORRIED ABOUT POTENTIAL NEGATIVE CONSEQUENCES FROM THEIR COWORKERS OR PEERS
DID NOT THINK THEIR REPORT WOULD BE KEPT CONFIDENTIAL
DID NOT WANT TO HURT THE PERSON’S CAREER
DID NOT WANT PEOPLE TO SEE THEM AS WEAK
THOUGHT THEY MIGHT GET IN TROUBLE FOR SOMETHING THEY HAD DONE OR WOULD GET LABELED A TROUBLEMAKER
WORRIED ABOUT POTENTIAL NEGATIVE CONSEQUENCES FROM THE PERSON(S) WHO DID IT
DID NOT TRUST THE PROCESS WOULD BE FAIR
WORRIED ABOUT POTENTIAL NEGATIVE CONSEQUENCES FROM A SUPERVISOR OR SOMEONE IN THEIR CHAIN OF COMMAND
THOUGHT IT MIGHT HURT THEIR PERFORMANCE EVALUATION/FITNESS REPORT OR THEIR CAREER
DID NOT WANT TO HURT THE PERSON’S FAMILY
SOME OTHER REASON

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Page 11 of 12

Per General Records Schedule (GRS) 5.2, 020, Intermediary Records, destroy after the information has
been captured in the Defense Sexual Assault Incident Database (DSAID).

CUI (when filled in)

129. OPTIONS AND INFORMATION DISCUSSED WITH THE INQUIRER

130. REFERRAL MADE (X one)

YES

NO

131. TYPE OF REFERRAL SUPPORT (X all that apply)
MEDICAL
BEHAVIORAL HEALTH
LEGAL/SPECIAL VICTIMS’ COUNSEL (SVC)
CHAPLAIN/SPIRITUAL SUPPORT
RAPE CRISIS CENTER
VICTIM ADVOCATE/UNIFORMED VICTIM ADVOCATE
DOD SAFE HELPLINE
CATCH ELECTION WITHOUT A REPORT
OTHER

DD FORM 2965, NOV 2024
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Page 12 of 12