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MALTREATMENT REPORT Page 1 of 2

PRIVACY ACT STATEMENT


AUTHORITY: PL93-247, "Child Abuse Prevention and Treatment Act" of 1974, DoD Directive 6400 1, "Family Advocacy Program".
PRINCIPAL To identify and record information on incidents of child and spouse abuse and provide protection and medical treatment to military
PURPOSES: members and their families.
ROUTINE USE(S): The Military Services use the information for internal management and maintain it by Service. Data forwarded to OSD will be aggregated
for analysis and void of case identifiers. Incident data is used to evaluate and identify protocols required in the case. Service program
managers use the data to identify incidence and prevalence rates and trends; track involved families; justify appropriate resource
allocation; and review and control providers of care.
DISCLOSURES: Voluntary, however, failure to provide information may delay the provision of appropriate services to the individual.

SECTION I – ADMINISTRATIVE DATA


CASE NO. INCIDENT NUMBER FAP RUC - FAP MCC STATE/COUNTRY INCIDENT REPORT DATE CLOSED DATE
10/27/2009
06820081744 0000006820080083 00000068 VA 3/10/2008 RESOLUTION
Resolved
REPORTING SERVICE ORGANIZATION NAME TYPE OF VICTIM TRANSFER INFORMATION
Child Adult Transfer In Date:
Marine Corps
Location:
VICTIM DECEASED Offender Known to DoD Central Registry NO YES Transfer Out Date:
Location:
Yes No Victim Known to DoD Central Registry NO YES

REFERRAL SOURCE ALLEGED OFFENDER RELATIONSHIP TO VICTIM


MALTREATMENT Relationship Extra familial Caregiver
Anonymous NCIS
Emotional Parent Military Child Care Center Pers.
Base Inspectors Office New Parent Support
Program Physical Spouse Military Family Child Care Pers.
Child Care One Source Neglect Sibling Military Youth Program Pers.
CID PMO/Blotter Report Sexual Other Family Member DoD Teacher/Other School Pers.
Civilian Court System Police/Sheriff
Extrafamilial Caregiver Other DoD Caregiver
Clergy School Personnel
Former Spouse
Command Self Referral – Offender
Intimate Partner
Counseling Services Self Referral – Victim
Non-Caregiver
CPS Service Member Acquaintance
Non-Caregiver Stranger
CSACC/Substance Abuse Social Services
Relationship Unknown
Family Member- Relative Transfer-in (Service Instal.)

Family Member - Spouse Transfer-in (USMC Instal.)


ALLEGED MATREATMENT DESCRIPTION:
FAP Tricare

Friend/Neighbor Victim Advocate

Legal/SJA Women’s Shelter/Family


Justice Center
Medical Other

Naval Hospital

CRC FINDINGS
Unsubstantiated – Unresolved Unsubstantiated – Did Not Occur Substantiated Date: 4/22/2008

NON-CRC FINDINGS Unsubstantiated – Referred for Services (LL/LR)

SECTION II – SPONSOR DATA


NAME SSN DATE OF BIRTH GENDER
(b)(6) Male

Female

UNIFORMED SERVICE SERVICE COMPONENT PAY PLAN TYPE GRADE SPONSOR ROLES
Army Guard Enlisted E3 Victim

Navy Regular Commissioned Officer Alleged Primary Offender

Marine Corps Reserve Warrant Officer Neither

Air Force Wage Grade

General Schedule

Perform Mgmt/Recog.
System
Sr. Executive Service

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MALTREATMENT REPORT Page 2 of 2

National Security Personnel


Sys.

SECTION III – VICTIM DATA


NAME SSN DATE OF BIRTH GENDER
(b)(6) Male

Female

SEVERITY CODES/MATRIX LEVEL: (1-5) SUBSTANCE INVOLVEMENT CLINICAL INTERVENTION


Emotional Alcohol FAP Personnel
Neglect
Drugs Other DoD-Funded Program/Individual
Physical 3
Sexual Unknown Non DoD-Funded Program/Individual

None No Treatment Provided

PERSONNEL TYPE RISK ASSESSMENT


Federal Civil Servant Mild

Uniformed Service Member Moderate

Civilian/Retired/Govt. Contractor Severe

Family Member

Non-Beneficiary

SECTION IV – ALLEGED PRIMARY OFFENDER DATA


NAME SSN DOB GENDER MARITAL STATUS DATE OF MARRIAGE
(b)(6) Male Married/Separated 2006

Female Divorced
OFFENDER KNOWN TO LOCAL CRC
Yes No Never Married

Widowed

Dual Military Marriage/Relationship

Combat Veteran

PERSONNEL TYPE SVC COMP UNIFORMED PAY PLAN TYPE GRADE SUBSTANCE
Guard SERVICE Enlisted INVOLVEMENT
Federal Civil Servant
Army Alcohol
Uniformed Service Regular Commissioned Officer
Member Navy Drugs
Reserve Warrant Officer
Civilian
Marine Corps Unknown
Wage Grade
Family Member
Air Force None
General Schedule
Non-Beneficiary
Perform Mgmt/Recog. Sys.

Sr. Executive Service

CLINICAL INTERVENTION
FAP Personnel Other DoD-Funded Program/Individual Non DoD-Funded Program/Individual No Treatment Provided

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