DD Form 2911 DoD Sexual Assault Forensic Examination (Safe) Report

DD Form 2911 - also known as the "Dod Sexual Assault Forensic Examination Report" - is a Military form issued and used by the United States Department of Defense.

The form - often incorrectly referred to as the DA form 2911 - was last revised on September 1, 2015. Download an up-to-date fillable DD Form 2911 down below in PDF-format or find it on the Department of Defense documentation website.

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DoD SEXUAL ASSAULT FORENSIC EXAMINATION (SAFE) REPORT
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Directive 6495.01, Sexual
Assault Prevention and Response (SAPR) Program; and DoD Instruction 6495.02, Sexual Assault
Prevention and Response (SAPR) Program Procedures.
PRINCIPAL PURPOSE(S): Information on this form will be used to document the medical/forensic
examination of the sexual assault victim. The DD Form 2911 also documents the reporting preference
(Restricted or Unrestricted) of the sexual assault victim as part of the sexual assault prevention and
response program.
ROUTINE USE(S): None.
DISCLOSURE: Completion of this form is voluntary; however, failure to complete this form with the
information requested impedes the effective management of care and support required by the
procedures of the sexual assault prevention and response program.
Patient Identification
Sensitive Information Document
PART I (NOTE: Conduct a SAFE for up to one full week following a sexual assault, or longer if circumstances dictate.)
A. GENERAL INFORMATION
(Print or type)
Type of Examination:
Name of Medical Facility:
Victim
Suspect
1a. NAME OF PATIENT
(Last, First, Middle Initial) (Skip if Restricted Report)
b. PATIENT ID NUMBER (Unrestricted Report only)
2a. ADDRESS
b. CITY
c. COUNTY
d. STATE
e. ZIP CODE
f. TELEPHONE (Include Area Code)
(1) Home:
(2) Work:
3a. AGE
b. DATE OF BIRTH
c. GENDER (X)
d. ETHNICITY (X)
e. RACE (X)
(YYYY/MM/DD)
(5) Native Hawaiian/
(1) Hispanic or
(1) American Indian/
(3) Black or African
M
Other Pacific Islander
Latino
Alaska Native
American
(2) Not Hispanic or
F
(2) Asian
(4) White
Latino
4a. ARRIVAL DATE
5a. DISCHARGE DATE
(YYYY/MM/DD)
(YYYY/MM/DD)
b. TIME
b. TIME
B. NOTIFICATION AND AUTHORIZATION:
Civilian or Foreign Assisting Agency:
Location of Assault:
Jurisdiction:
Other
On Installation
Off Installation
City
County
1a. NAME OF SEXUAL ASSAULT RESPONSE COORDINATOR
c. TELEPHONE (Include Area Code)
b. VICTIM DECLINED SARC
(SARC)
(Last, First, Middle Initial)
AND SAPR VA SERVICES
2a. NAME OF SEXUAL ASSAULT FORENSIC EXAMINER
b. RANK
c. TITLE
d. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)
3a. NAME OF VICTIM ADVOCATE (VA)
(Last, First, Middle Initial)
b. TELEPHONE (Include Area Code)
4a. NAME OF MILITARY CRIMINAL INVESTIGATIVE OFFICER (UNRESTRICTED REPORT)
b. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)
c. AGENCY
d. ID NUMBER
e. DATE (YYYY/MM/DD)
5a. NAME OF SERVICE DESIGNATED EVIDENCE COLLECTING OFFICER (RESTRICTED REPORT)
b. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)
c. AGENCY
d. ID NUMBER
e. DATE (YYYY/MM/DD)
f. TIME
g. RESTRICTED REPORT
(RRCN)
CONTROL NUMBER
C. REPORTING INFORMATION
1. In unrestricted reporting, I understand that Military Medical Treatment Facilities and Healthcare Providers are required by Department of
(Initial)
Defense regulations to report sexual assaults to Military Criminal Investigative Organization (MCIO) authorities (e.g., CID, NCIS, AFOSI).
Under these circumstances, the report must state the name of the injured person, current whereabouts, and the type and extent of injuries.
In Restricted reporting, I understand that Military Medical Treatment Facilities and Healthcare Providers are required by Department of
Defense regulations to report sexual assaults to the Sexual Assault Response Coordinator (SARC).
(Initial)
2. a. The Sexual Assault Response Coordinator (SARC) and/or Sexual Assault Prevention and Response Victim Advocate (SAPR VA) have
explained the difference between Unrestricted and Restricted Reporting options.
b. I understand that I have the right to speak to my own attorney (Special Victims' Counsel or Victim Legal Counsel) before electing a
(Initial)
reporting option.
c. I have elected:
UNRESTRICTED REPORTING
RESTRICTED REPORTING
(Only applicable to Active Duty, and Reserve and
(Initial)
National Guard in active service or inactive duty training, adult military dependent.)
(Initial)
3. I understand what my options are and do not have questions.
DD FORM 2911, SEP 2015
Page 1 of 14 Pages
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
DoD SEXUAL ASSAULT FORENSIC EXAMINATION (SAFE) REPORT
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Directive 6495.01, Sexual
Assault Prevention and Response (SAPR) Program; and DoD Instruction 6495.02, Sexual Assault
Prevention and Response (SAPR) Program Procedures.
PRINCIPAL PURPOSE(S): Information on this form will be used to document the medical/forensic
examination of the sexual assault victim. The DD Form 2911 also documents the reporting preference
(Restricted or Unrestricted) of the sexual assault victim as part of the sexual assault prevention and
response program.
ROUTINE USE(S): None.
DISCLOSURE: Completion of this form is voluntary; however, failure to complete this form with the
information requested impedes the effective management of care and support required by the
procedures of the sexual assault prevention and response program.
Patient Identification
Sensitive Information Document
PART I (NOTE: Conduct a SAFE for up to one full week following a sexual assault, or longer if circumstances dictate.)
A. GENERAL INFORMATION
(Print or type)
Type of Examination:
Name of Medical Facility:
Victim
Suspect
1a. NAME OF PATIENT
(Last, First, Middle Initial) (Skip if Restricted Report)
b. PATIENT ID NUMBER (Unrestricted Report only)
2a. ADDRESS
b. CITY
c. COUNTY
d. STATE
e. ZIP CODE
f. TELEPHONE (Include Area Code)
(1) Home:
(2) Work:
3a. AGE
b. DATE OF BIRTH
c. GENDER (X)
d. ETHNICITY (X)
e. RACE (X)
(YYYY/MM/DD)
(5) Native Hawaiian/
(1) Hispanic or
(1) American Indian/
(3) Black or African
M
Other Pacific Islander
Latino
Alaska Native
American
(2) Not Hispanic or
F
(2) Asian
(4) White
Latino
4a. ARRIVAL DATE
5a. DISCHARGE DATE
(YYYY/MM/DD)
(YYYY/MM/DD)
b. TIME
b. TIME
B. NOTIFICATION AND AUTHORIZATION:
Civilian or Foreign Assisting Agency:
Location of Assault:
Jurisdiction:
Other
On Installation
Off Installation
City
County
1a. NAME OF SEXUAL ASSAULT RESPONSE COORDINATOR
c. TELEPHONE (Include Area Code)
b. VICTIM DECLINED SARC
(SARC)
(Last, First, Middle Initial)
AND SAPR VA SERVICES
2a. NAME OF SEXUAL ASSAULT FORENSIC EXAMINER
b. RANK
c. TITLE
d. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)
3a. NAME OF VICTIM ADVOCATE (VA)
(Last, First, Middle Initial)
b. TELEPHONE (Include Area Code)
4a. NAME OF MILITARY CRIMINAL INVESTIGATIVE OFFICER (UNRESTRICTED REPORT)
b. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)
c. AGENCY
d. ID NUMBER
e. DATE (YYYY/MM/DD)
5a. NAME OF SERVICE DESIGNATED EVIDENCE COLLECTING OFFICER (RESTRICTED REPORT)
b. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)
c. AGENCY
d. ID NUMBER
e. DATE (YYYY/MM/DD)
f. TIME
g. RESTRICTED REPORT
(RRCN)
CONTROL NUMBER
C. REPORTING INFORMATION
1. In unrestricted reporting, I understand that Military Medical Treatment Facilities and Healthcare Providers are required by Department of
(Initial)
Defense regulations to report sexual assaults to Military Criminal Investigative Organization (MCIO) authorities (e.g., CID, NCIS, AFOSI).
Under these circumstances, the report must state the name of the injured person, current whereabouts, and the type and extent of injuries.
In Restricted reporting, I understand that Military Medical Treatment Facilities and Healthcare Providers are required by Department of
Defense regulations to report sexual assaults to the Sexual Assault Response Coordinator (SARC).
(Initial)
2. a. The Sexual Assault Response Coordinator (SARC) and/or Sexual Assault Prevention and Response Victim Advocate (SAPR VA) have
explained the difference between Unrestricted and Restricted Reporting options.
b. I understand that I have the right to speak to my own attorney (Special Victims' Counsel or Victim Legal Counsel) before electing a
(Initial)
reporting option.
c. I have elected:
UNRESTRICTED REPORTING
RESTRICTED REPORTING
(Only applicable to Active Duty, and Reserve and
(Initial)
National Guard in active service or inactive duty training, adult military dependent.)
(Initial)
3. I understand what my options are and do not have questions.
DD FORM 2911, SEP 2015
Page 1 of 14 Pages
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
D. PATIENT CONSENT
1. I understand that the Sexual Assault Forensic Examination
YES
(also known as a "SAFE") that I am about to undergo is
optional. When I give my consent, a healthcare
NO
professional may examine me to find and collect evidence
of an assault. I understand that as part of the examination,
(Initial)
the provider can collect specimens such as urine and/or
blood.
Patient Identification
(Initial)
YES
2. I understand that I may withdraw my consent at any time for any portion of the examination and that it
will not impact my right to medical care.
NO
(Initial)
YES
3. I understand that collection of evidence may include photographing injuries and that these photographs
may include the genital area.
NO
(Initial)
4. I understand that samples of my blood and/or urine may need to be tested for drugs as part of my
YES
treatment. I also understand that testing for drugs will also show prescriptions, other drugs, and
alcohol that I have voluntarily consumed. I understand that illegal drugs or alcohol (if I am under
NO
age 21) in my body could be used to show that I engaged in misconduct if I am a Service member.
I consent to this testing.
(Initial)
5. I understand that some of the information that I provide may be collected for health and forensic
YES
purposes and provided to health authorities and other qualified persons for a valid educational or
scientific interest and/or epidemiological studies. However, none of my personally identifying data
NO
(name, patient identification number, etc.) will be disclosed for these purposes.
(Initial)
YES
6. I hereby consent to a sexual assault medical forensic examination (SAFE).
NO
(Initial)
YES
7. If I have elected to make an Unrestricted Report, I understand and consent to the release of my records
and all evidence collected from this exam to MCIO.
NO
(Initial)
YES
8. In cases where the military does not have jurisdiction over the offense, evidence may be turned over
to a state or Federal law enforcement agency.
NO
(Initial)
YES
9. If I have elected to make a Restricted Report, I understand that my records and all evidence collected
should not be reviewed or tested unless I choose to convert to an Unrestricted Report.
NO
(Initial)
10. I understand that any evidence, including personal property, collected in an Unrestricted Report shall be
YES
retained by MCIO and not returned to me until the conclusion of all legal, adverse action, and adminis-
trative proceedings. Additionally, in a Restricted Report any personal property retained as part of the
NO
Sexual Assault Forensic Examination (SAFE) will be retained and not returned to me for a period of
5 years in accordance with legal requirements and DoD policy.
b. DATE
c. TIME
11a. PATIENT SIGNATURE
(YYYY/MM/DD)
12. WITNESS TO PATIENT SIGNATURE
a. SIGNATURE
b. ADDRESS
c. DATE
d. TIME
(Include ZIP Code)
(YYYY/MM/DD)
DD FORM 2911, SEP 2015
Page 2 of 14 Pages
E. PATIENT HISTORY
1a. NAME OF PERSON PROVIDING HISTORY
(Last, First, Middle Initial)
b. RELATIONSHIP TO PATIENT
c. DATE (YYYY/MM/DD)
d. TIME
2. PERTINENT MEDICAL HISTORY
Patient Identification
a. LAST MENSTRUAL PERIOD b. Any recent (60 days) anal-genital injuries, surgeries, diagnostic procedures, or medical treatment that may affect the interpretation of
current physical findings? (If yes, describe)
No
Yes
c. Any other pertinent medical condition(s) that may affect the interpretation of current physical findings? (If yes, describe)
No
Yes
d. Any pre-existing physical injuries? (If yes, describe)
No
Yes
3. PERTINENT NON-ASSAULT RELATED HISTORY
Do NOT record any other information regarding sexual history on this form.
a. Other non-assault sexual activity within past 5 days?
No
Yes
Unsure
If yes or unsure, complete items b. through f. below. If no, then check the "No" box to the left and proceed to item 4.
No
Yes
Unsure
(X and complete as applicable)
(If Yes)
b. Anal (within past 5 days)?
When?
c. Vaginal (within past 5 days)?
When?
d. Oral (within past 5 days)?
When?
e. Did ejaculation occur?
Where?
f. Was a condom used?
4. POST-ASSAULT HYGIENE/ACTIVITY
Not Applicable if over 5 days
No
Yes
No
Yes
(X and complete as applicable)
a. Urinated
h. Brushed teeth
b. Defecated
i. Gargled/mouthwash
c. Genital or body wipes (If yes, describe)
j. Vomited
k. Ate or drank
d. Douched (If yes, with what)
l. Used cream/ointment/lotion on body part involved in assault (If yes,
describe)
e. Removed/inserted
m. Changed clothing (If yes, describe)
Tampon
Diaphragm
Nuva ring
n. Changed body piercings (If yes, describe)
f. Oral gargle/rinse
g. Bath/shower/wash
F. ASSAULT HISTORY
1a. DATE OF ASSAULT(S)
(YYYY/MM/DD)
2. LOCATION AND PERTINENT PHYSICAL SURROUNDINGS
b. TIME
3. PHYSICAL EFFECTS OF ASSAULT. If injuries are described or if remarkable findings or possible trauma are observed, please photograph.
a. Non-genital injury, pain and/or bleeding (including tenderness). (If yes, describe.)
No
Yes
b. Genital/rectal injury, pain and/or bleeding (including tenderness). (If yes, describe.)
No
Yes
4. INJURIES INFLICTED UPON THE ASSAILANT(S) DURING ASSAULT?
(If yes, describe injuries, possible locations on the body, and how they were inflicted.)
No
Yes
5a. NUMBER OF ASSAILANT(S)
b. ASSAILANT(S) RELATIONSHIP TO VICTIM (Indicate/number all that apply)
Stranger
Acquaintance
Relative (Specify)
Other (Specify)
DD FORM 2911, SEP 2015
Page 3 of 14 Pages
G. PATIENT'S DESCRIPTION OF THE ASSAULT
Please record the patient's description of the assault.
Add additional pages if necessary.
Patient Identification
DD FORM 2911, SEP 2015
Page 4 of 14 Pages
H. ACTS DESCRIBED BY PATIENT
- Describe any penetration of the genital, anal or oral opening,
no matter how slight or brief.
- Type of sexual intercourse (oral, vaginal, anal).
- If more than one assailant, identify by number.
Patient Identification
1. PENETRATION OF VAGINA BY
Unsure Describe:
No
Yes
Attempted
a. Penis
b. Finger
c. Object (If yes, describe the object)
2. PENETRATION OF ANUS BY
No
Yes
Attempted Unsure Describe:
a. Penis
b. Finger
c. Object (If yes, describe the object)
3. ORAL COPULATION OF GENITALS
Attempted Unsure Describe:
No
Yes
a. Of patient by assailant
b. Of assailant by patient
4. ORAL COPULATION OF ANUS
No
Yes
Attempted Unsure Describe:
a. Of patient by assailant
b. Of assailant by patient
5. NON-GENITAL ACT(S)
No
Yes
Attempted Unsure Describe:
a. Licking
b. Kissing
c. Suction injury
d. Biting
e. Strangulation/choking
6. OTHER ACT(S)
(Describe)
7. DID EJACULATION OCCUR?
No
Yes
Unsure
(If yes, location(s))
Mouth
Rectum
Other
(note location(s))
Vagina
Body surface
Genitals
On clothing
Anus
On bedding
8. CONTRACEPTIVE OR LUBRICANT PRODUCT(S)
Describe Type/Brand, if known:
No
Yes
Unsure
a. Condom used?
b. Lubricant used?
c. Other Contraceptive used?
DD FORM 2911, SEP 2015
Page 5 of 14 Pages

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