OPNAVINST 5530 14

INCIDENT REPORT

INCIDENT NUMBER

REPORT TYPE
INITIAL SUPPLEMENTAL

AUTHORITY: 5 U.S.C. 301; 10 U.S.C. 5031; 44 U.S.C. 3103; and EO 9397 PRIVACY ACT STATEMENT PRINCIPAL PURPOSE: Used to record information and details of criminal activity which may require investigative action by commanding officers, supervisors, security police, NCIS special agents, ect. Used to provide information to the appropriate individuals within DoD organizations who ensure that the proper legal and administrative action is taken. ROUTINE USES: Information may be disclosed to local, country, state and federal law enforcement or investigatory authorities for investigation and possible criminal prosecution or civil court action. Information extracted from this form may be used in other related criminal and/or civil proceedings. DISCLOSURE IS VOLUNTARY: SSN is used to positively identify the individual making the statement and as a condult to check past criminal activity records. SECTIONS OR BLOCKS THAT DO NOT APPLY TO A REPORTD OFFENSE SHOULD BE LEFT BLANK SECTION I. ADMINISTRATIVE
DATE REC'D (YYYYMMDD) TIME REC'D (24 Hour) INCIDENT RECEIVED: In Person By Alarm By Telephone By Crime Stop Call/ 911 By Radio Other:

SECTION II. COMPLAINANT (if not victim/witness) (Use "Complainant/Witness/Sponsor" Addendum sheet for additional Complainants)
LAST NAME (Include Jr., Sr., II, III, ect.) FIRST MIDDLE SSN/ALIEN REG. #: GRADE/RANK

BRANCH OF SERVICES: MARINE CORPS

ARMY

NAVY

AIR FORCE OTHER:

STATUS:

REG. (ACTIVE) FAM. MEM.

RESERVE CIVILIAN EMP.

RETIRED

NATIONAL GUARD

COAST GUARD

CIVILIAN (NO GOV. AFF.) WORK TELEPHONE STATE ZIP CODE

DUTY STATION/EMPLOYER (INCLUDE DEPARTMENT/COMMAND/DIVISION/UNIT/ect.) ADDRESS CITY

UIC/RUC

SECTION III. OFFENSE (Use "Offense" Addendum for additional Offenses)

TIME(S) OF INCIDENT: (24 Hour) From: To:

OFFENSE STATUS: (Check Only One Per 0ffense) 1. ATTEMPTED COMPLETED 2. 3. ATTEMPTED COMPLETED ATTEMPTED COMPLETED

From:

To:

OFFENSE DATA No. STATUTORY BASIS OFFENSE DESCRIPTION LOCATION/ADDRESS

(SEE CODE BELOW)

1. 2. 3. * STATUTORY BASIS CODES: (U) UCMJ (F) Federal (S) State (L) Local (X) Foreign OFFENDER USED Alcohol Drugs/Narcotics Computer Equipment Not applicable Handgun Rifle Shotgun

WEATHER CONDITIONS: (Max.3)

LIGHTING:

Daylight Dusk Dawn

Dark (Lighted) Dark (Not Lighted) Unknown

TYPE WEAPON/FORCE USED (Max 3) (Enter in box an "A"if fully automatic weapon; "M" if manual; "S" if semi-automatic) Firearm (Not Listed) Knife/Cutting Tool Blunt Object Motor Vehicle Bodily Force (Hands/Feet) U.S. & Possessions Rental/Storage Facility Lake/Waterway/Ocean Construction Site Hospital/Clinic Child Care Facility Specialty Store/Concessionaire Quarters/Barracks/Residence/Berthing Motor Pool/Parking Lot/Garage Operating/Promoting/Assisting Possessing/Concealing Transporting/Transmitting/Importing Using/Consuming PREVIOUS EDITION IS OBSOLETE. Destruction/Vandalism Harassment/Stalking Other: (Specify) Poison Explosives Fire/Incendiary Narcotic/Drug Asphyxiation Unknown None Other (Specify) Outside U.S. & Possessions Dining Facility/Restaurant Bank/Credit Union Service/Gas Station On Board Ship On Board Aircraft Other (Specify) Unknown

LOCATION OF OFFENSE (Enter 1, 2, or 3 if multiple offenses occurred at different locations) Exchange/Dept/Discount Store School (Elem,High)/College NCO Club/Officer Club/Bar Government/Public Building BOQ/CBQ/Lodge/Hotel Package/Liquor Store Shoppette/Convenience Store Corrections Facility/Jail/Prison Buying/Receiving Cultivating/Manufacturing/Publishing Distributing/Selling Exploiting Children Air/Bus/Train Terminal Training/Service School Training Area/ Field/Woods Highway/Road/Alley/Sidewalk Commissary/Grocery Store Chapel/Church/Synagogue Commercial/Office Building Recreation Area/Park

TYPE OF CRIMINAL ACTIVITY (If larceny, forgery, pornography, gambling, drugs, or weapons violation) (MAX 3)

OPNAV 5580/1 (Rev Nov 2006)

FOR OFFICAL USE ONLY (When filled in)

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SECTION III. OFFENSE (cont.) VEHICLE DESCRIPTION

BURGLERY/B & E ONLY:

Force

No Force

# Of Premises Entered

Sedan (2DR/4DR)

None Anti-White Anti-Black Anti-Arab Anti-Hispanic

BIAS MOTIVATION (X)(All Hate/Bias Motivated Offenses Must Be Reported to NCIS) Anti-Alaskan Native Anti-Catholic Anti-Asian Anit-Pacific Islander Anti-Other Ethnicity/Origin Anti-Multi-Racial Group Anti-Jewish Anti-Islamic (Moslem) Anit-Protestant Anti-Multi-Religious Group Anti-Other Religion Anti-Atheism
SERIAL # COLOR VALUE S/U (c) OWNER (d)

METHOD OF ENTRY (Max.3) Door Knob Twist Remain On Premise Door Kicked In Tunneled Door Open/Unlocked Screen Cut Screen Pried Door Pried Door other Screen Removed Screen Other Delivery Widow Broken Garage Widow Cut Bodily Force Widow Open/Unlocked Sliding Door Door Type Other Widow Pried Open Window Removed Lock Cut/Removed Window Other Lock Force/Broken Cut Hole In Wall Lock Force (HASP) Unknown Lock Pried Other: Lock Other

CONDITION OF PREMISE (Max.1) Occupied Unoccupied Vacant (Temp. Unocc.) Vacant TOOLS USED (Max.3) Bar/Pipe Bodliy Force Bolt Cutters Chopping Tool Explosive Gripping Tool Hammer Pry Tool Saw/Drill Wire Screwdriver Misslle Unknown Other:

INCIDENT NUMBER

Anti-Agnostic Anti-Homosexual Anti-Male Homosexual Anti-Female Homosexual Anti-Heterosexual Anti-Bisexual

Anti-American Indian SECTION IV. PROPERTY (Use "Property" Addendum sheet for additional Property)
CODE TYPE QTY (a) (b) DESCRIPTION MAKE/MODEL SIZE

a. PROPERTY DESCRIPTION CODE 01 - Aircraft 02 - Alcohol 03 - Automobile 04 - Bicycle 05 - Bus 06 - Clothes/Furs 07 - Computer Hard/Software 08 - Consumable Goods 09 - Credit/Debit Cards 10 - Drugs/Narcotics 11 - Drugs Narcotic Equipment 12 - Farm Equipment 13 - Firearms 14 - Gambling Equipment 15 - Heavy Construction Equip. 16 - Household Goods 17 - Jewelry/Precious Metals 18 - Livestock 19 - Merchandise 20 - Money 21 - Negotiable Instruments 22 - Nonnegotiable Instruments c. S/U CODE 23 24 25 26 27 28 29 30 31 32 33Office-Type Equipment Other Motor Vehicles Purse/Handbag/Wallet Radio/TV/Visual Recording-Audio/Visual Recreational Vehicle Structures - Single Occupancy Structures - Other Dwellings Structures - Commercial/Bus Structures - Industrial/Manuf. Structures - Public/Community d. OWNERSHIP CODE 34 - Structures - Storage 35 - Structures - Other 36 - Tools - Power/Hand 37 - Trucks 38 - Vehicle Parts/Accessories 39 - Watercraft 77 - Other (Specify) 88 - Pending Inventory 99 - Special Category

b. TYPE PROPERTY LOSS/ECT. CODE (1) None (2) Burned (3) Counterfeited /Forget (4) Damaged/Destroyed (7) Stolen (5) Recovered (8) Unknown (6) Seized (9) Lost & Found

e. DISPOSITIONS OF PROPERTY CODE (E) Evidence (R) Return to Owner (S) Safekeeping

(A) Federal Gov. (D) County Gov. (S) SECURE (B) State Gov. (E) Foreign Gov. (U) UNSECURE (C) City Gov. (F) Private/Personal

SUSPECTED DRUG INVOLVMENT DRUG TYPE (f) EST. QUANTITY

f. DRUG TYPE
(H) Other Narcotics (I) LSD (J) PCP (K) Other Hallucinogens (L) Amphetamines (M) Other Stimulants (N) Barbiturates (O) Other Depressants (P) Other Drugs (U) Unknown Drug (X) Over 3 Drug Types

g. TYPE DRUG MEASUREMENT

MEASURMENT(g) (A) "CRACK" cocaine (G) Opium

UNITS (DU) Dosage Unit (pills, ect.) (NP) Number of plants VICTIM RELATED TO OFFENSE # 1 2 3 4 5 6 7 8 9 10

SECTION V. VICTIM (Use "Victim" Addendum sheet if more than one victim)

VICTIM#

DD2701 ISSUED

VICTIM RELATED TO SUPECT # YES NO 1 2 3 4 5 6 7 8 9 10 FIRST MIDDLE STATUS: REG. (ACTIVE) FAM. MEM. RESERVE CIVILIAN EMP. UIC/RIC. RETIRED NATIONAL GUARD CIVILIAN (NO GOV. AFF.) WORK TELEPHONE GRADE/RANK

LAST NAME (include Jr., Sr., II, III, ect.) BRANCH OF SERVICES: MARINE CORPS

SSN/ALIEN REG. #:

ARMY

NAVY

AIR FORCE OTHER:

COAST GUARD

DUTY STATION/EMPLOYER (INCLUDE DEPARTMENT/COMMAND/DIVISION/ect.) ADDRESS DOB POB OPNAV 5580/1 (Rev Nov 2006)
Male Female Unknown

CITY SEX
White Black American Indian

STATE ETHNICITY
Asian Unknown Hispanic Non-Hispanic Unknown

ZIP CODE RESIDENT STATUS

RACE

PREVIOUS EDITION IS OBSOLETE.

FOR OFFICAL USE ONLY (When filled in)

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