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
20090223 Fort Bragg 01NOV2008 05NOV2008 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 Yes Yes CIVILIAN: Law Enforcement 0

Originating Installation Maltreatment Type(s)

for Transfer-In Case Alleged Investigation Source Victim Protective Actions
Physical Civilian Law Enforcement 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 Alleged Offender 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
30 REDACTED REDACTED 01JAN1920 Female White, 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 Substance Army FAP Providers No
Involvement Involvement
Unknown Unknown

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 White, Not Army
Hispanic

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 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
16DEC2008 MetCriteria PHYSICAL: Moderate

SECTION VI - CLOSURE

Date Incident Closed by CRC Incident Close Reason

12FEB2009 Maltreatment Reduced or No Longer Present

SECTION VII - AUTHENTICATION

Date Incident Closed

by CRC AUTHENTICATING OFFICIAL SIGNATURE
16NOV2010 . Electonically Signed

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974