DoD Independent Review Related to Fort Hood

Secretary of Defense

Dr. Robert M. Gates

Co-Chairs

The Honorable Togo Dennis West, Jr. Admiral Vern Clark, U.S. Navy (Ret).

Board of Advisors

Admiral Kirkland Donald, U.S. Navy

General Stephen Lorenz, U.S. Air Force

General Carter Ham, U.S. Army

Lieutenant General Willie Williams, U.S. Marine Corps

Brigadier General Brian Bishop, U.S. Air Force

Rear Admiral Daniel May, U.S. Coast Guard 

Team Leads

General Stephen Lorenz, U.S. Air Force

General Carter Ham, U.S. Army

Lieutenant General Frank Panter, U.S. Marine Corps

Rear Admiral Mark Buzby, U.S. Navy

Rear Admiral Karen Flaherty, U.S. Navy

Ms. Sally Donnelly

Executive Director

Colonel David Krumm, U.S. Air Force

Director of Staff

Lieutenant Colonel Donna Turner, U.S. Air Force
Table of Contents

i

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Protecting the Force: Lessons from Fort Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Identifying Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Sharing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Force Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Who is in Charge? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Reacting to the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The Alleged Perpetrator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Going Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 1 Oversight of the Alleged Perpetrator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Chapter 2 Personnel Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Indicators that DoD Personnel May Become a Danger to Themselves or Others . . . . . . . . . . . . . . . . . . . . . . 11

Reporting and Sharing Information About the Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Barriers or Constraints on Taking Action ...................................................... 22

Chapter 3 Force Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Authorities/Command and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Indications and Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Information Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Access Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Chapter 4 Emergency Response and Mass Casualty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Implementation of Enhanced 911 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Law Enforcement Practices–Active Shooter Threat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Mass Warning and Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Common Operational Picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Synchronization of Emergency Management Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Mutual Aid Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Emergency Family Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Religious Support Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Memorial Service Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Private Citizens with No DoD Affiliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Chapter 5 Support to DoD Healthcare Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Mental Health Care Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
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Appendix A Memorandum and Terms of Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

Appendix B Panel Roster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

Appendix C Summary of Findings and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1

Appendix D Literature Review of Risk Factors for Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1

Predicting Violent Behavior is a Long-Term Multi-Disciplinary Quest . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1

Risk Factors Vary Across Types of Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1

Application for the Department of Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-4
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Executive Summary

Overview

On November 5, 2009, a gunman opened fire at the Soldier Readiness Center at Fort Hood, Texas. 

Thirteen people were killed and 43 others were wounded or injured. The initial response to the incident 

was prompt and effective. Two minutes and forty seconds after the initial 911 call, installation first 

responders arrived on the scene. One-and-a-half minutes later, the assailant was incapacitated. Two 

ambulances and an incident command vehicle from the post hospital arrived on the scene two minutes 

and fifty seconds later.

Leaders at Fort Hood had anticipated mass casualty events in their emergency response plans and 

exercises. Base personnel were prepared and trained to take appropriate and decisive action to secure the 

situation. The prompt and courageous acts of Soldiers, first responders, local law enforcement personnel, 

DoD civilians, and healthcare providers prevented greater losses. As so often happens in our military, 

lessons already learned have led to a well-developed plan to care for the victims and families involved. 

The tragedy, however, raised questions about the degree to which the entire Department is prepared for 

similar incidents in the future—especially multiple, simultaneous incidents.

Following the shooting, Defense Secretary Robert M. Gates established the Department of Defense 

Independent Review Related to Fort Hood, and asked that we lead the effort.

Secretary Gates directed us to report back to him by January 15, 2010, with recommendations to 

identify and address possible deficiencies in:

• the Department of Defense’s programs, policies, processes, and procedures related to force protection 

and identifying DoD employees who could potentially pose credible threats to themselves or others;

• the sufficiency of the Department of Defense’s emergency response to mass casualty situations at DoD 

facilities and the response to care for victims and families in the aftermath of mass casualty events;

• the sufficiency of programs, policies, processes, and procedures for the support and care of healthcare 

providers while caring for beneficiaries suffering from Post Traumatic Stress Disorder or other mental 

and emotional wounds and injuries;

• the adequacy of Army programs, policies, processes, and procedures as applied to the alleged 

perpetrator.

In response, on November 20, 2009, we formed a panel of five teams to assist in conducting the review. 

At the same time, we established an advisory board that included senior representatives nominated by 

each of the Services, the Joint Staff, and the U.S. Coast Guard. A staff of full-time military, civilian, and 

contractor subject-matter experts conducted separate, but integrated lines of inquiry related to:

• Identification of Internal Personnel Threats

• Force Protection

• Emergency Response and Mass Casualty

• Application of Policies and Procedures

• Support to DoD Healthcare Providers

The review focused on the non-criminal aspects of the tragedy and the teams had unrestricted access to 

DoD facilities and personnel, including site visits to Fort Hood. The investigative teams conducted a 

thorough review of the alleged perpetrator’s training and military records along with a quality review of 
2

the care he provided to patients during his career. The President directed a review of intelligence matters 

related to the Fort Hood shooting, the FBI is conducting a review of its procedures, and a criminal 

investigation is underway. It was critical to maintain the integrity of these investigations. This review 

therefore, as directed, did not interfere with these activities.

As recognized by the Secretary of Defense in stating that he intends to call upon the military 

departments to conduct in-depth follow-on reviews based on our results, areas in our report will require 

further study. By design, we have limited the depth of our report in areas that will be covered in followon reviews.

Conducting our review, we have reached a number of conclusions and made corresponding 

recommendations; they are reflected in the chapters that follow. Several, however, warrant particular 

attention. We address those now.

Protecting the Force: Lessons from Fort Hood

Over much of the past two decades our forces have been engaged 

in continuous combat operations. During this time, Soldiers, 

Sailors, Airmen, Marines, and DoD civilians have performed 

admirably through a prolonged series of operational deployments. 

This operational environment has produced the most experienced 

combat force in our history, but has also brought extended stressors.

The Department of Defense is well-equipped and resourced to 

defend the nation, its people, and our military installations against 

external threats. Events such as the Fort Hood shooting, however, 

raise questions about how best to defend against threats posed 

by external influences operating on members of our military 

community. While maintaining effective emergency response and 

preventive measures to counter external threats, the Department 

is examining with greater attention how it addresses threats 

originating from disaffected individuals within the force motivated 

to violence against the force and the nation—the internal threat. Our review of protecting the force 

against such threats included, but was not limited to:

• identifying and monitoring potential threats—through gathering, analyzing, and acting on 

information and intelligence;

• providing time-critical information to the right people—through merging and sharing current 

indicators;

• employing force protection measures—through maintaining adequate preventive measures to 

mitigate threats;

• planning for and responding to incidents—through immediate emergency response as well as the 

long-term care for victims of attacks and their families.

In the years since September 11, 2001, the Department of Defense has devoted significant energy 

and resources toward improving force protection for our people, their families, and our installations. 

Events such as the 

Fort Hood shooting 

raise questions 

about how best 

to defend against 

threats posed by 

external influences 

operating on 

members of our 

military community. 
3

DoD force 

protection policies 

are not optimized 

for countering 

internal threats....

The lack of clarity 

for comprehensive 

indicators limits 

commanders’ 

and supervisors’ 

ability to recognize 

potential threats. 

Executive Summary

Consequently, our facilities are more secure and at reduced risk from a variety of external threats . Now 

is the time to devote that same commitment toward force protection against the internal threat .

Identifying Threats

Th ere are areas where guidance within the Department of Defense 

and the Services can be improved . Our review of DoD programs, 

policies, procedures, and processes revealed several areas that 

we believe can be corrected to begin to close the gaps for our 

commanders in the fi eld if adopted expeditiously . Commanders 

are our key assets to identify and monitor internal threats . Our 

fi ndings and recommendations emphasize creating clarity for 

our commanders with respect to identifying behaviors that may 

pose internal threats and sharing that information within the 

Department and with other agencies .

DoD force protection policies are not optimized for countering 

internal threats . Th ese policies refl ect insuffi cient knowledge 

and awareness of the factors required to help identify and 

address individuals likely to commit violence . Th is is a key 

defi ciency . Th e lack of clarity for comprehensive indicators limits 

commanders’ and supervisors’ ability to recognize potential threats . Current eff orts focus on forms of 

violence that typically lend themselves to law enforcement intervention (e .g ., suicide, domestic violence, 

gang-related activities) rather than on perceptions of potential security threats . To account for possible 

emerging internal threats, we encourage the Department to develop comprehensive guidance and 

awareness programs that include the full range of indicators for potential violence .

Sharing Information

We believe a gap exists in providing information to the right people . Th e mechanisms for sharing 

potential indicators of internal threats with appropriate command channels are limited . DoD leaders 

have continually examined and revised policies regarding inappropriate behavior since the mid-1990s—

our force is better as a result of these initiatives . We now fi nd ourselves at a point where we must give 

commanders the tools they need to protect the force from new challenges .

Since the Fort Hood incident, our leaders have directed changes that improve our information sharing 

capabilities . We can and should do more . Th e time has passed when bureaucratic concerns by specifi c 

entities over protecting “their” information can be allowed to prevent relevant threat information 

and indicators from reaching those who need it—the commanders . In this rapidly changing security 

environment throughout our government, the Department of Defense can exercise its role to set the 

bar higher to establish a new force protection culture, with new standards and procedures for sharing 

information, to recognize and defeat evolving external and internal threats .
4

Force Security

The current definition for prohibited activities is incomplete 

and does not provide adequate guidance for commanders and 

supervisors to act on potential threats to security. Current policies 

on prohibited activities provide neither the authority nor the tools 

for commanders and supervisors to intervene when DoD personnel 

at risk of potential violence make contact or establish relationships 

with persons or entities that promote self-radicalization. Our 

commanders need that authority now.

As we seek to understand this new dimension of force protection, 

our commanders must become attuned to behavioral indicators 

that signal when individuals may commit violent acts or become 

radicalized. There is no well-integrated means to gather, evaluate, 

and disseminate the wide range of behavioral indicators which could 

help our commanders better anticipate an internal threat. We need 

to refine our understanding of what these behavioral signals are and how they progress. We encourage 

the Department of Defense to review, and if necessary expand, the definition of prohibited activities to 

respond to the rapidly changing security environment.

Who is in Charge?

An effective protection system requires robust information sharing and command and control structures 

that facilitate active information gathering on potential threats, and disseminating the analysis and 

assessments of the threat derived from such indicators to the appropriate levels of command. While 

leaders at Fort Hood responded well under the stress of a rapidly evolving crisis, we are fortunate that we 

faced only one incident at one location. We cannot assume that this will remain the case in the future.

Our command and control systems must have the right architecture, connectivity, portability, and 

flexibility to enable commanders to cope with near-simultaneous incidents at multiple locations. 

Commanders also require the tools to intercept threats before they conduct their attacks, physical 

barriers, and access controls to prevent unauthorized access, and appropriate response forces to defeat 

attackers who have gained access to DoD facilities.

Considering the requirements for dealing with multiple, near-simultaneous incidents similar to Fort 

Hood, a review of the Unified Command Plan may be in order. Gaps in our ability to provide proper 

command and control and support to subordinate commands should be explored in a variety of ways 

including conferences, symposia, war games, and exercises.

Reacting to the Event

While major improvements have occurred since September 11, 2001, the Department of Defense 

must continue to refine its abilities to provide emergency response in concert with other agencies and 

jurisdictions. In 2009, the Department directed the Services to be in compliance with the Federal 

framework for emergency response by 2014. Compliance with this guidance will enhance the ability 

...our commanders 

must become 

attuned to 

behavioral 

indicators that 

signal when 

individuals may 

commit violent 

acts or become 

radicalized.
5

of the Department’s installation and facility emergency personnel to work with fi rst responders from 

Federal, State, and local jurisdictions to save lives and protect property . We encourage a review to assess 

the feasibility of accelerating our compliance with the deadline .

Mass casualty events require a rapid transition from normal operations 

to a surge capability and rapid coordination of services and functions 

to ensure eff ective disaster response . Th e life-saving response to the 

shooting at Fort Hood was made possible, in part, by strong leadership 

at all levels . It also depended on existing agreements with local agencies 

and organizations . Th e agreements worked, but the command has 

identifi ed areas for improvement and has set a course to update its 

memoranda of understanding and otherwise to improve this process . 

To this end, we recommend improving guidance on tracking, exercising, 

and inspecting mutual aid agreements . Providing implementing 

guidance that incorporates the core Service elements and requirements 

for family assistance in crisis and mass casualty response plans will 

result in a more resilient force .

We especially note that as a result of the Force Protection Condition imposed by Fort Hood leadership 

during the crisis, a number of young school children remained closeted in their classrooms for a 

signifi cant period . Our recommendation is that those responsible for them at school (e .g ., teachers, 

administrative personnel) receive additional training to anticipate the special needs that could arise 

during a period of lengthy lockdown .

Th e Fort Hood response to the shooting was a result of local commanders 

training their people before the crisis occurred . First responders used 

active shooter tactics and procedures to stop the attack one-and-a-half 

minutes after arriving on the scene . Th ese new tactics, originating in 

civilian law enforcement, focus on neutralizing the threat as quickly as 

possible . Protecting the force relies on a unifi ed eff ort to mitigate threats 

before they materialize, and employing security forces, including those 

trained to defeat active shooters, in response to attacks on DoD facilities .

We believe there is something positive to be learned from the active 

shooter training program employed at Fort Hood . Protecting the force 

against internal threats requires specialized skills and tactics required to 

respond to active shooter scenarios; while these capabilities may not be 

appropriate for all DoD law enforcement personnel, we need to develop a 

range of response capabilities and options . We encourage the Department 

of Defense to search for best practices such as those employed at Fort Hood—wherever they originate—

to enhance our ability to protect the force .

Traumatic events, especially those like the Fort Hood incident that occur in an environment perceived 

as safe, create new challenges related to supporting and treating individuals directly involved, those in 

the immediate community, and those in surrounding social networks . Long term behavioral health is 

the issue . We recommend establishing guidance that includes provisions for both combat and domestic 

support .

Executive Summary

The life-saving 

response to the 

shooting at Fort 

Hood was made 

possible, in 

part, by strong 

leadership at all 

levels.

We encourage 

the Department 

to search for 

best practices 

such as those 

employed at Fort 

Hood—wherever 

they originate—

to enhance our 

ability to protect 

the force.
6

Our examination underscored that the Chaplain Corps has a great deal to offer in a mass casualty 

situation. Responding to mass casualty events requires more than the traditional first responder 

disciplines such as police, fire, and medical professionals. Comprehensive religious support that 

anticipates mass casualty incidents should be incorporated into installation emergency management 

plans and exercises.

The Department of Defense has a structure to promulgate guidance for Casualty Assistance and 

Mortuary Affairs Policy. Each program has an oversight board responsible for developing and 

recommending policy guidance to ensure uniform care of military members and their families and 

guidance pertaining to new casualty and mortuary entitlements.

Lessons derived from the Fort Hood incident emphasize the importance of current published 

entitlements in DoD and Service guidance and the need for further guidance regarding new 

entitlements. Our review highlighted an absence of guidance pertaining to private citizens who become 

casualties on military installations within the continental United States. The Department of Defense 

should evaluate policies for casualty reporting, assistance to the survivors, and mortuary services for 

private citizens who are injured or die on military installations.

Our healthcare providers play an important role as force multipliers, 

keeping our fighting force physically and mentally fit. How we handle 

military mental healthcare affects operational readiness. We encourage 

the Department of Defense to evaluate the best programs both inside 

and outside the Department to inform policies that create a new 

standard for sustaining healthcare readiness—care for both warriors 

and providers.

Our care providers are not immune to the cumulative psychological effects of persistent conflict. 

They serve alongside our combat forces where they experience, share, and help our troops cope with 

the fears, grief, and concerns that accompany war. Providers, however, often do not avail themselves 

of access to support resources similar to those that they supply to our fighting forces. Our review 

suggests that a culture exists in which military healthcare providers are encouraged to deny their own 

physical, psychological, and social needs to provide the necessary support to beneficiaries. Supporting 

and sustaining those who care for our forces translates to a healthy workplace, a culture of trust and 

respect, and healthcare providers who are invigorated rather than depleted by their intimate professional 

connections with traumatized patients.

The Alleged Perpetrator

As directed in the Terms of Reference, we reviewed the accession, training, education, supervision, 

and promotion of the alleged perpetrator of the incident at Fort Hood. Through one of our teams, we 

have devoted a great deal of attention to this issue. As a result of our review, we recommend that the 

Secretary of the Army review officership standards among military medical officer supervisors at the 

Uniformed Services University of the Health Sciences and Walter Reed Army Medical Center.

A related issue involves apparent discrepancies between the alleged perpetrator’s documented 

performance in official records and his actual performance during his training, residency, and fellowship. 

How we handle 

military mental 

healthcare affects 

operational 

readiness.
7

Some signs were clearly missed; others ignored . Th at, too, as well as accountability for the discrepancies 

should be part of a thorough Army review .

Going Forward

We recognize that the events of November 5, 2009, are, fi rst and foremost, a tragedy for all involved: 

families, colleagues, and the nation . Th is event shows us, too, that there are no safe havens—for 

Soldiers, Sailors, Airmen, Marines, their co-workers and their families . 

Th e challenge for the Department of Defense is to prepare more 

eff ectively for a constantly changing security environment . Th e 

Department’s security posture for tomorrow must be more agile and 

adaptive . Th is means structures and mechanisms which anticipate 

the most pressing current threats—like the insider threat today—

and the new threats that will manifest themselves in the future .

It has been said that it takes an event to make us consider what is 

happening to us . In light of events at Fort Hood on November 5, 2009, and of our fi ndings in this 

report, we believe there are several immediate actions the Secretary of Defense should consider which 

will enhance our force protection posture .

• Communicate immediately to the force, by direct message from the Secretary, the overriding 

requirement for commanders, supervisors, non-commissioned leaders, and fellow members of 

the force to reinforce the fabric of trust with one another by engaging, supervising, mentoring, 

counseling, and simple everyday expressions of concern on a daily and continuous basis . We must 

be alert to the mental, emotional, and spiritual balance of Service members, colleagues, and civilian 

coworkers, and respond when they appear at risk .

• Reinforce the serious eff ects of failure to refl ect fully, accurately, and completely all aspects of 

professional, ethical, and personal career development in performance appraisals . We can only deal 

with internal threats if we can rely on the quality of the information reported in our offi cial records .

• Emphasize offi cership, the embodiment of the military profession that includes leadership, 

management, and mentoring . Responding to the challenges that now confront us requires a high 

degree of professionalism from the entire force, but especially from our offi cers . Our offi cer corps 

must instill and preserve the core traits that sustain the profession to keep our forces strong, eff ective, 

and safe . Failures in adhering to those standards must be appropriately addressed .

• Synchronize the Continental United States (CONUS)-based DoD emergency management program 

with the national emergency management framework . Our installations must have a common 

operating system that allows commanders to access real-time threat information, respond rapidly to 

changing force protection conditions, and begin response and recovery operations in near real time . 

Th is is an aggressive goal, but it matches the goals and character of future enemies .

• Act immediately with the Federal Bureau of Investigation to enhance the operation of the Joint 

Terrorism Task Forces . To protect the force, our leaders need immediate access to information 

pertaining to Service members indicating contacts, connections, or relationships with organizations 

promoting violence . One additional step may be to increase Service representation on the Joint 

Terrorism Task Forces .

Executive Summary

The Department’s 

security posture 

for tomorrow must 

be more agile and 

adaptive.
8

• Create a Secretary of Defense initiative: establish a functional body to concentrate in one place the 

effort to gather, analyze, and interpret data useful in identifying indicators of potential for violent 

action; and create a comprehensive and usable catalogue of those indicators with constant updates. 

The products would be made available to the Department of Defense. Two such possibilities 

are a Secretary of Defense Initiative on Indicators of Violence, or a Defense Committee on the 

Recognition of the Indicators of Violence. These would be composed of acknowledged experts 

drawn from in and outside the Department, such as academia, research institutes, business, former 

public service, and the like operating under the oversight of an appropriate senior Defense official.

As the Department of Defense considers this review and seeks to improve its force protection posture, 

our leaders must be mindful that the vast majority of our people are trustworthy and dedicated to 

defending the nation. How we provide for the security of our installations, our personnel, and their 

families while simultaneously respecting and honoring their service, is a question that will define force 

protection, personnel policies, emergency response, and personnel oversight in the years to come.

Vern Clark Togo Dennis West, Jr.

Admiral, U.S. Navy (Ret) Co-Chair

Co-Chair
9

Chapter 1

Oversight of the Alleged Perpetrator

We reviewed pertinent Uniformed Services University of the Health Sciences (USUHS) and Army 

programs, policies, processes, and procedures as applied to the alleged perpetrator from his accession 

into USUHS in 1997 to November 4, 2009. This period included his medical training while a student 

at USUHS from 1997 to 2003, residency at Walter Reed Army Medical Center from 2003 to 2007, a 

fellowship at Walter Reed Army Medical Center from 2007 to 2009, and assignment at Fort Hood from 

May 2009 to November 2009.

This part of the review assessed:

• the adequacy and execution of Army programs, policies, processes, and procedures as applied to the 

alleged perpetrator;

• whether Army and other programs, policies, processes, and procedures functioned properly across 

the alleged perpetrator’s career as a mental health provider to retain and promote him in the Army 

Medical Corps;

• whether Army programs, policies, processes, and procedures governing separation from the Army 

of personnel determined not to be fully qualified, or to be unsuitable for, continued military service 

(without regard to whether the individual is subject to a continuing service obligation), functioned 

appropriately as applied to the alleged perpetrator;

• whether the care provided by the alleged perpetrator to patients and former patients met accepted 

standards of care.

We conclude that although the policies we reviewed were 

generally adequate, several officers failed to comply with those 

policies when taking actions regarding the alleged perpetrator. 

We recommend that you refer matters of accountability for those 

failures to the Secretary of the Army for appropriate action.

We also recommend that you direct further action on two 

key concerns identified during our review. We believe that 

some medical officers failed to apply appropriate judgment and 

standards of officership with respect to the alleged perpetrator. 

These individuals failed to demonstrate that officership is the 

essence of being a member of the military profession, regardless of 

the officer’s specialty. We also found that some medical officers 

failed to include the alleged perpetrator’s overall performance as an officer, rather than solely his academic 

performance, in his formal performance evaluations. An individual’s total performance, academic and nonacademic, in a school environment must be a part of the formal performance evaluation process to preclude 

decisions on that individual’s career from being flawed because of incomplete information.

Both types of failures, in our view, were significant and warrant immediate attention.

Our detailed findings, recommendations, and complete supporting discussions, are the restricted annex, 

some portions of which are not releasable to the public in accordance with applicable law.

Our review also included a quality of care review of the clinical care the alleged perpetrator provided to 

patients. A memorandum summarizing those results is in the annex. Section 1102 of title 10, United 

States Code, prohibits the public disclosure of the results of quality of care reviews.

We conclude that 

although the policies 

we reviewed were 

generally adequate, 

several officers failed 

to comply with those 

policies when taking 

actions regarding the 

alleged perpetrator.
10

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11

We reviewed over 700 documents spanning more than 35,000 pages of DoD and Service directives, 

instructions, regulations, manuals, command policies, orders, memoranda, and pamphlets, for potential 

gaps in the Department of Defense’s ability to prevent violent acts against military and civilian 

employees with two objectives: 

• Identify and address possible gaps and deficiencies in the programs, policies, processes, and 

procedures related to identifying DoD military and civilian personnel who could potentially pose 

credible threats to themselves or others.

• Provide actionable recommendations to improve current programs, policies, processes, and procedures.

We limited the review to military personnel (i.e., Active Duty, National Guard, Reserves), and DoD 

civilian employees over the lifecycle of DoD employment—from entry to separation. The review did 

not include Non-Appropriated Fund employees, contractors, retirees, dependents, or policy related to 

union bargaining agreements. Although we did not address policies concerning contractors, we strongly 

recommend that they be addressed in a future review.

At the foundation of the Department of Defense’s internal security apparatus, we found that there are no 

significant gaps or deficiencies in programs, policies, processes, and procedures related to the following:

• Personal reliability programs

• Service Member release and discharge policies and procedures

• Medical screening programs to determine initial suitability prior to specialization, and follow-on/

ongoing screening

We separated our Findings and Recommendations into the following categories:

• Indicators that DoD personnel may become a danger to themselves or others

• Reporting and sharing information about the indicators

• Barriers or constraints on taking action or intervention when the indicators are known or 

recognized by appropriate authority

Indicators that DoD Personnel May 

Become a Danger to Themselves or Others

Finding 2.1

DoD programs, policies, processes, and procedures that address identification of indicators for violence 

are outdated, incomplete, and fail to include key indicators of potentially violent behaviors.

Discussion 

Research into the causes and predictors of violence spans decades and multiple disciplines (see Appendix D, 

Literature Review of Risk Factors for Violence). Different disciplines (e.g., psychology, sociology, biology, 

theology) offer varying perspectives regarding why some people resort to violence. These include genetic and 

biological causes; specific mental illnesses and personality disorders; reactions to medications or substance 

abuse; religion, social, and political motivations; and environmental factors. The causes of violence do not fall 

neatly into discrete categories, and several factors may combine to trigger violent behaviors.

Chapter 2

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12

The Department of Defense needs to understand and be prepared for the wide range of motivations and 

methods, including self-radicalization, distress over relationship problems, association with hate groups, 

and resentment over perceived personal and professional slights by others within the organization. 

Research also highlights a range of risk-assessment tools that could enhance our ability to deal with such 

potential internal threats.

In October 2009, the FBI Behavioral Science Unit established a Military Violence Unit to assist the 

Department of Defense with coming to grips with this problem. The FBI has spent decades developing 

methodologies and collecting information to understand the motivations and behaviors of violent 

offenders. The expertise and perspective derived from law enforcement could be an effective step in 

helping to identify and mitigate risk factors for DoD personnel.

Recommendation 2.1

• Update training and education programs to help DoD personnel identify contributing factors and 

behavioral indicators of potentially violent actors.

• Coordinate with the FBI Behavioral Science unit’s Military Violence unit to identify behavioral 

indicators that are specific to DoD personnel.

• Develop a risk assessment tool for commanders, supervisors, and professional support service 

providers to determine whether and when DoD personnel present risks for various types of violent 

behavior.

• Develop programs to educate DoD personnel about indicators that signal when individuals may 

commit violent acts or become radicalized.

Finding 2.2

Background checks on personnel entering the DoD workforce or gaining access to installations may be 

incomplete, too limited in scope, or not conducted at all.

Discussion 

Background checks on civilians entering the military or DoD civilian workforce have a variety of 

limitations. State and local laws restrict access to some sealed juvenile records.

1

 Some populations 

(medical, legal, and chaplain officers who receive Direct Commissions into the Reserves2 and some 

civilian employees3) enter the workforce before the results of their background checks have been received, 

and a limited number of DoD employees (i.e., temporary civilian workers) are not subject to mandatory 

background checks at all, although they can be requested.

4

In the Fort Hood incident, the alleged perpetrator held an active and current SECRET security clearance 

based on a February 2008 National Agency Check with Local Agency and Credit Check of background 

investigation. Although accomplished in accordance with current guidelines, this background 

investigation did not include a subject interview or interviews with co-workers, supervisors, or expanded 

1 Title 5 USC, Part III, Subpart H, Chapter 91, Section 9101, Access to Criminal History Records for National Security and Other Purposes, Jan. 1, 2005.

2 Department of Defense. DoD 5200.2-R, Personnel Security Program, Washington, D.C., Feb. 23, 1996, 33-4.

3 Department of Defense. DoD 5200.2-R, Personnel Security Program, Washington, D.C., Feb. 23, 1996, 32.

4 Department of Defense. DoD 5200.2-R, Personnel Security Program, Washington, D.C., Feb. 23, 1996, 31.
13

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character references .5 We believe that if a more thorough investigation had been accomplished, his 

security clearance may have been revoked and his continued service and pending deployment would have 

been subject to increased scrutiny .6

DoD adjudicative guidelines are vague and training on how and 

to whom signifi cant information reports are made is insuffi cient . 

Th ey do not provide commanders and their personnel with clear 

distinctions or thresholds for what constitutes signifi cant information 

that should be forwarded . Instead, the criteria refl ect “whole person” 

evaluations that are characterized by shades of gray .7 Our research 

revealed that limitations on defi nitions of questionable behaviors 

result in an aversion to reporting potentially adverse information that 

does not cross the threshold of criminal activity once a clearance has 

been granted .8

 Th e result is a system in which information viewed in 

isolation may not trigger a review, but the totality of the information 

viewed in hindsight would clearly indicate a need for such a review .

Due to the critical demand for linguists, interrogators, cultural advisors, etc ., for contingency operations, 

DoD elements have developed expedited processes for citizenship and clearances for DoD personnel . 

Th ese processes are more limited in scope and could be exploited by adversary groups .

Recommendation 2.2

• Evaluate background check policies and issue appropriate updates .

• Review the appropriateness of the depth and scope of the National Agency Check with Local Agency 

and Credit Check as minimum background investigation for DoD SECRET clearance .

• Educate commanders, supervisors, and legal advisors on how to detect and act on potentially adverse 

behaviors that could pose internal threats .

• Review current expedited processes for citizenship and clearances to ensure risk is suffi ciently 

mitigated .

Finding 2.3

DoD standards for denying requests for recognition as an ecclesiastical endorser of chaplains may be 

inadequate .

5 Telephone Interview with Deputy Director of the Army CAF . Washington, D .C ., Dec . 3, 2009 . 

6 Department of the Army . AR 380-67, Personnel Security Program, Washington, D .C ., Sep . 9, 1988, 15-16 .

7 “National Security Positions .” Code of Federal Regulations Title 5, Pt . 732 .101-401, 1991 ed ., Jan . 4, 2004; Offi ce of the White House Press Secretary . 

Executive Order 12968, Access to Classifi ed Information, Washington, D .C ., Aug . 4, 1995; Th e White House . “Adjudicative Guidelines for Determining 

Eligibility for Access to Classifi ed Information,” Washington, D .C ., Dec . 29, 2005; Department of the Army . AR 380-67, Personnel Security Program;

Department of the Navy . SECNAVI 5510 .30B, Personnel Security Program, Washington, D .C ., Oct . 6, 2006; United States Air Force . AFI 31-501, 

Personnel Security Program Management, Washington, D .C ., Jan . 27, 2005 .

8 Interview with HQ USMC Manager for Information and Personnel Security Program . Washington, D .C ., Dec . 16, 2009 .

DoD adjudicative 

guidelines are 

vague and training 

on how and to 

whom significant 

information 

reports are made is 

insufficient.
14

Discussion

Each religious organization that provides military chaplains provides an endorsing agent to serve as its 

representative to the Department of Defense. These endorsing agents issue and withdraw professional 

credentials in accordance with the practice of their religious organizations. Current policy requires 

removal of any individual or religious organization from participation in the DoD Chaplain program 

only if they threaten national or economic security, are indicted or convicted of an offense related to 

terrorism, or if they appear on the annual State Department list of Foreign Terror Organizations. This 

limited authority to deny requests for designation as ecclesiastical endorsers could allow undue improper 

influence by individuals with a propensity toward violence.

Recommendation 2.3

Review the limitations on denying requests for recognition as ecclesiastical endorsers of chaplains.

Finding 2.4

The Department of Defense has limited ability to investigate Foreign National DoD military and 

civilian personnel who require access to DoD information systems and facilities in the U.S. and abroad.

Discussion

This further relates to finding, discussion, and recommendation 2.2.

A number of populations presently granted physical access to DoD facilities require some form of vetting for 

repeated access. Vetting is often a one-time event that does not provide for continuous re-investigation or reevaluation for the duration of DoD affiliation. For the notionally vetted populations, some records do not exist, 

and large numbers of people who gain access to our facilities are not vetted at all under current procedures. The 

Department of Defense’s ability to investigate foreign national DoD employees who live outside of the U.S. and 

require access to DoD facilities is very limited. The Department of Defense is only able to conduct the FBI name 

check, fingerprint check, and a check of the known and suspected terrorist databases.

Recommendation 2.4

Coordinate with the Department of State and Office of Personnel Management to establish and 

implement more rigorous standards and procedures for investigating Foreign National DoD personnel.

Finding 2.5

The policies and procedures governing assessment for pre- and post-deployment medical risks do not 

provide a comprehensive assessment of violence indicators.

Discussion 

This further relates to finding, discussion, and recommendation 2.1.

DoD and Service policies provide broad pre-deployment guidance on health risk assessment,9

 and 

9 Department of Defense. DoDI 6490.03, Deployment Health, Washington, D.C., Aug. 11, 2006, 27; Department of Defense. DoDI 6025.19, Individual Medical 

Readiness, Washington, D.C., Jan. 3, 2006, 4.
15

Chapter 2

Personnel Policies

specifi c guidance on a variety of high-risk health conditions .10 Guidance on high-risk health conditionsis 

useful to healthcare providers currently treating service members . Th ere is no global violence risk 

assessment performed during pre-deployment for Service members not currently receiving healthcare . 

Post-deployment assessments, performed at the end of deployment and three to six months after 

deployment, rely primarily on self-report screening questionnaires11 to identify risk factors . Th ese 

screening questionnaires address issues such as post-traumatic stress, traumatic brain injury, substance 

abuse, depression, and suicide—there are no screening questions to assess the potential to harm others . 

Moreover, the assessments do not address additional risk factors (i .e ., fi nancial, occupational, relationship 

stressors) thought to be associated with the potential for violence .

Recommendation 2.5

• Assess whether pre- and post-deployment behavioral screening should include a comprehensive 

violence risk assessment .

• Review the need for additional post-deployment screening to assess long-term behavioral indicators 

that may point to progressive indicators of violence .

• Revise pre- and post-deployment behavioral screening to include behavioral indicators that a person 

may commit violent acts or become radicalized .

• Review policies governing sharing healthcare assessments with commanders and supervisors to allow 

information regarding individuals who may commit violent acts to become available to appropriate 

authorities .

Finding 2.6

Th e Services have programs and policies to address prevention and intervention for suicide, sexual assault, and family 

violence, but guidance concerning workplace violence and the potential for self-radicalization is insuffi cient .

Discussion 

Th is further relates to fi nding, discussion, and recommendation 2.2.

Suicide Prevention,12 Sexual Assault Prevention & Response,13 and Family Advocacy14 programs address 

numerous facets of violence . Family Advocacy and Sexual Assault Prevention & Response programs 

10 Department of Defense . ASD Policy Memo on Guidance for Deployment Limiting Psychiatric Conditions & Medications, Washington, D .C ., Nov . 7, 2006, 1-7 .

11 Department of Defense . DD Form 2796, Post Deployment Health Assessment (PHDA), Washington, D .C ., January 2008, 1-7; Department of Defense . 

DD Form 2900, Post Deployment Health Assessment (PHDA), Washington, D .C ., January 2008, 1-5 .

12 Department of the Air Force . AFI 44-154, Suicide and Violence Prevention Education and Training, Washington, D .C ., Jan . 3, 2003/Aug . 28, 2006, 2-18; 

Department of the Army . AR 600-63, Army Health Promotion, Washington, D .C ., Sep . 20, 2009, 13; Department of the Navy . OPNAVINST 1720 .4A, 

Suicide Prevention Program, Washington, D .C ., Aug . 4, 2009, 1-10; Department of the Navy . MCO P1700 .24B, Marine Corps Personal Services Manual,

Washington, D .C ., Dec . 27, 2001, 3-8 .

13 Department of Defense . DoDD 6495 .01, Sexual Assault Prevention and Response Program, Washington, D .C ., Oct . 6, 2005/Nov . 7, 2008, 1-5; 

Department of the Air Force . AFI 36-6001, Sexual Assault Prevention and Response Program, Washington, D .C ., Sep . 29, 2009, 5-30; Department of 

the Navy . SECNAVINST 1752 .4A, Sexual Assault Prevention and Response, Dec . 1, 2005, 1-5; Department of the Army . AR 600-20, Army Command 

Policy, Washington, D .C ., Nov . 30, 2009, 68-82; Department of the Navy . MCO 1752 .5, Sexual Assault Prevention and Response Program, Marine Corps 

Personal Services Manual, Washington, D .C ., Sep . 28, 2004 .

14 Department of the Defense . DoDD 6400 .01, Family Advocacy Program, Washington, D .C ., Aug . 23, 2004, 2-5; Department of the Air Force . AFI 40-301, Family 

Advocacy, Washington, D .C ., Nov . 30, 2009, 5-30; Department of the Army . AR 608-18, Family Advocacy Program, Washington, D .C ., Oct . 30, 2007, 11-71; 

Department of the Navy . SECNAVINST 1752 .3B, Family Advocacy Program, Nov . 10, 2005, 1-16; Department of the Navy . MCO P1700 .24B, Marine Corps 

Personal Services Manual, Washington, D .C ., Dec . 27, 2001, 5-4 .
16

in each of the Services are implemented based on DoD level guidance, 

while Suicide Prevention programs are implemented by each of 

the Services without specific DoD level policy. The policies and 

procedures at the DoD or Service level that address workplace violence 

are not comprehensive. Where current policy or programs exist, they 

are limited, not widely disseminated, and implemented inconsistently.

15 

For example, Air Force Instruction 44-154, Suicide and Violence 

Prevention Education and Training, addresses training for both violence 

and suicide prevention, but the violence prevention portion of annual 

training was recently eliminated. In recent years, the Services have 

developed programs that address preventing violence in various 

populations.

16 These may serve as useful resources for developing more 

comprehensive workplace violence prevention—including the potential 

for self-radicalization. Useful resources for violence prevention 

education and training also exist in other federal agencies but are dated 

and not integrated into DoD policies, procedures, or processes.

17

Recommendation 2.6

• Revise current policies and procedures to address preventing violence toward others in the workplace.

• Integrate existing programs such as suicide, sexual assault, and family violence prevention with 

information on violence and self-radicalization to provide a comprehensive prevention and response 

program.

Finding 2.7

DoD policy regarding religious accommodation lacks the clarity necessary to help commanders 

distinguish appropriate religious practices from those that might indicate a potential for violence or 

self-radicalization.

Discussion

DoD Instruction 1300.17, Accommodation of Religious Practices within the Military Services, states that 

requests for religious accommodation should be granted when the practice will not have an adverse 

impact on mission accomplishment, military readiness, unit cohesion, standards, or discipline.

18 It does 

not, however, provide standards or recording procedures necessary to establish a baseline of traditional 

religious practice within faith groups. The Department of Defense has not issued clear guidance 

on the degree to which the Religious Freedom Restoration Act19 applies to the military. Therefore, 

commanders, supervisors, and chaplains lack a common source to distinguish mainstream religious 

15 Senior military mental health providers consulted for the DoD Fort Hood Independent Review Panel.

16 Army Warrior Transition Center Policy Memo: Warrior Transition Unit/Community-Based Warrior Transition Unit (WTU/CBWTU) Risk Assessment 

& Mitigation Policy (Draft pending approval); Department of the Air Force. SG DOC: 06-0009, Memorandum, ALMAJCOM/SG, Washington, D.C., 

Oct. 14, 2005, 1-9; Combat and Operational Stress First Aid for Caregivers Training Manual (Draft pending approval).

17 Office of Personnel Management. Dealing with Workplace Violence: A Guide for Agency Planners, February 1998; Office of Personnel Management. A 

Manager’s Handbook: Handling Traumatic Events, Washington, D.C., December 1996.

18 Department of Defense. DoDI 1300.17, Accommodation of Religious Practices Within the Military Services, Washington, D.C., Feb. 10, 2009, 2.

19 Title 42, USC Chapter 21B, Religious Freedom Restoration, Section 2000bb-1, Free Exercise of Religion Protected, Washington, D.C., Jan. 8, 2008.

Useful resources 

for violence 

prevention 

education and 

training also exist 

in other federal 

agencies but are 

dated and not 

integrated into 

DoD policies, 

procedures, or 

processes.
17

practices from extreme practices for faith groups . Service policies and procedures, therefore, vary in 

stating and reporting standards of religious accommodation .20

If requests for religious accommodation that compete with mission requirements were recorded and 

shared among commanders, supervisors, and chaplains, it would help establish a baseline from which to 

identify deviations within the Services and the Department of Defense . At present, there is confusion 

about what is acceptable .

For example, the Air Force requires personnel who request waivers for accommodation of religious 

apparel to be interviewed by a chaplain to assess whether the request is in keeping with doctrinal or 

traditional observances of the Service member’s faith . Th en the installation’s senior chaplain must 

document the fi ndings before forwarding to the commander for a decision . Th e Services have diff erent 

procedures for handling religious accommodation requests . None of this information is shared, even 

when serving together at joint bases or in deployed locations .

Th is lack of clarity creates the potential for denying information to commanders and supervisors that 

may signal indicators of self-radicalization or extremist behavior . Commanders and supervisors may not 

recognize unusual religious practices outside traditional norms within faith groups . Current procedures 

do not provide consistent mechanisms for initiating appropriate action to prevent an escalation toward 

violence .

Clear standards would enhance commanders’ and supervisors’ ability to promote the climate necessary 

to maintain good order and discipline, and would reduce both the instances and perception of 

discrimination among those whose religious expressions are less familiar to the command .21

Recommendation 2.7

Promptly establish standards and reporting procedures that clarify guidelines for religious accommodation .

Finding 2.8

DoD Instruction 5240 .6, Counterintelligence (CI) Awareness, Briefi ng, and Reporting Programs, does 

not thoroughly address emerging threats, including self-radicalization, which may contribute to an 

individual’s potential to commit violence .

Discussion

Th is relates to fi nding, discussion, and recommendation 2.1.

DoD Instruction 5240 .6, Counterintelligence (CI) Awareness, Briefi ng, and Reporting Programs, provides 

guidance to conduct defensive counterintelligence and counter-terrorism awareness briefi ngs to DoD 

personnel . Th is instruction does not, however, provide specifi c, updated guidance to the Services, 

Combatant Commands, and appropriate agencies concerning behavioral indicators that could identify 

self-radicalization, terrorism, or violence . Researchers and intelligence professionals have been actively 

20 Department of the Army . AR 165-1, Chaplain Activities in the United States Army, Religious Support, Washington, D .C ., Dec . 3, 2009, 1, 9; Department 

of the Navy . SECNAVINST 1730 .8B, Accommodation of Religious Practices, Washington, D .C ., Oct . 2, 2008, 1-9; Department of the Air Force . AFPD 

52-1, Chaplain Service, Washington, D .C ., Oct . 2, 2006, 2 .

21 Department of Defense . DoDI 1300 .17, Accommodation of Religious Practices Within the Military Services, Washington, D .C ., Feb . 10, 2009, 1-2 .

Chapter 2

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18

engaged in identifying trends in this domain, particularly since September 11, 2001.

22 The absence of an updated 

and comprehensive policy on emerging threats inhibits the timely update of relevant Service regulations.

Recommendation 2.8

Update DoD Instruction 5240.6 to provide specific guidance to the Services, Combatant Commands, 

and appropriate agencies for counterintelligence awareness of the full spectrum of threat information, 

particularly as it applies to behavioral indicators that could identify self-radicalization.

Reporting and Sharing Information About the 

Indicators

Finding 2.9

DoD and Service guidance does not provide for maintaining and transferring all relevant information 

about contributing factors and behavioral indicators throughout Service members’ careers.

Discussion

This relates to finding, discussion, and recommendation 2.1 and 2.2.

The only information that follows Service members across all assignments is contained in performance 

evaluations and medical records. Other information may be required, but those requirements vary 

across the Services.

23 Some information included in these files is temporary, however, and is barred 

from becoming part of permanent records.

24 For example, Service policies place strong emphasis 

on commander discretion to record and/or forward information about minor law enforcement or 

disciplinary infractions.

25 Successful completion of substance abuse counseling is another example of 

information that may not be included in Service member records, but research studies show that ongoing 

or past alcohol and drug abuse can lead to violent acts.

26

The result is that significant additional information is kept at local levels, or for limited periods of time, 

and is therefore unavailable to future commanders and supervisors. Similarly, incoming commanders 

and supervisors may lack visibility into some relevant events that occurred prior to their arrival (although 

some programs such as the Marine Corps’ Family Readiness Officer Initiative aim to bridge some of 

these gaps27). Federal law and DoD implementing policies direct certain types of information that 

22 Paul K. Davis and Kim Cragin, eds. Social Science for Counterterrorism. (2009); Carol Dyer, Ryan E. McCoy, Joel Rodriguez, and Donald N. Van Duyn.

“Countering Violent Islamic Extremism.” FBI Law Enforcement Bulletin (2007): 3-9; Samuel Nunn. “Incidents of Terrorism in the United States, 

1997-2005.” Geographical Review 97:1 (2007): 89-111; Sánchez-Cuenca, Ignacio and Luis de la Calle. “Domestic Terrorism: The Hidden Side of Political 

Violence.” Annual Review of Political Science 12 (2009): 31-49; Smith, Brent. “A Look at Terrorist Behavior: How They Prepare, Where They Strike.” NIJ 

Journal 26p0 (2008): 2-6; Austin T. Turk “Sociology of Terrorism.” Annual Review of Sociology 30 (2004): 271-86.

23 Department of Army. AR 600-37, Unfavorable Information, Washington, D.C., Dec. 19, 1986, 3; Department of the Air Force. AFI 36-2608, Military 

Personnel Record System, Washington, D.C., Aug. 30, 2006, 36; Department of the Navy. BUPERSINST 1070.27B, Document Submission Guidelines for 

the Electronic Military Personnel Record System, Washington, D.C., Aug. 26, 2005, 2-4.

24 Department of the Navy. MCO P1070.12K, Marine Corps Individual Records Administration Manual, Washington, D.C., July 14, 2000, 1-4, 1-7.

25 Ibid.

26 U.S. Army Center for Health Promotion and Preventive Medicine, Investigation of Homicides at Fort Carson, Colorado, Nov. 2008-May 2009, July 

2009, Table B-6, “Risk Factor Characteristics by Index Case Based on Record Review and Administrative Databases,” B-14.

27 Department of the Navy. NAVMC Directive 1754.6A, Marine Corps Family Team Building, Washington, D.C., Jan. 30, 2006, 2-3 through 2-6; 

Department of the Navy. MCO 1754.6A, Marine Corps Family Team Building, Washington, D.C., Jan. 30, 2006, 4-5, 7.
19

must and/or cannot be maintained .28 Th e Department of Defense’s review of guidance for retaining and 

sharing of additional information should include a recommendation on modifying applicable statutes 

and policies . 

Recommendation 2.9

• Review what additional information (e .g ., information about accession waivers, substance abuse, 

minor law enforcement infractions, conduct waivers) should be maintained throughout Service 

members’ careers as they change duty locations, deploy, and re-enlist .

• Develop supporting policies and procedures for commanders and supervisors to access this 

information .

Finding 2.10

Th ere is no consolidated criminal investigation database available to all DoD law enforcement and 

criminal investigation organizations .

Discussion

DoD criminal investigation organizations have limited ability to search for or analyze information 

outside their own databases; they must query other DoD criminal investigation organizations to obtain 

specifi c investigative information . Th is limitation restricts investigative eff orts for searches or analysis of 

data outside of each Service and could reduce the eff ectiveness of law enforcement to prevent, detect, or 

investigate criminal activity .

Current initiatives regarding joint basing, coupled with the routine 

formation of Joint Task Forces, highlight the importance of sharing 

investigative data among the Services . Th e Department of Defense 

has recognized this shortfall and supported implementation of a 

Defense Law Enforcement Exchange, using the Naval Criminal 

Investigative Service’s Law Enforcement Information Exchange (LInX) 

as a model . LInX is a database established to apply search and link 

analysis tools by providing access to structured and unstructured data 

across organizations, including Federal, State, county, and municipal 

agencies .

Recommendation 2.10

Establish a consolidated criminal investigation and law enforcement 

database such as the Defense Law Enforcement Exchange .

Finding 2.11

DoD guidance on establishing information sharing agreements with Federal, State, and local law 

enforcement and criminal investigation organizations does not mandate action or provide clear standards .

28 36 Code of Federal Regulation, Part 1220, Federal Records - General, Washington, D .C ., Nov . 2, 2009; 36 Code of Federal Regulation, Part 1222, 

Creation and Management of Federal Records, Washington, D .C ., Nov . 2, 2009; Department of Defense . DoDD 5525 .5, DoD Cooperation with Civilian 

Law Enforcement Offi cials, Washington, D .C ., Jan . 15, 1986/ Dec . 20, 1989, 3 .

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Personnel Policies

Current initiatives 

regarding joint 

basing, coupled 

with the routine 

formation of 

Joint Task Forces, 

highlight the 

importance 

of sharing 

investigative 

data among the 

Services. 
20

Discussion 

This relates to finding, discussion, and recommendation 2.10.

DoD policy requires the Secretaries of the Military Departments and Directors of the Defense Agencies 

to establish local contact points in subordinate commands for coordination with Federal, State, and local 

civilian law enforcement officials.

29 The Services have implemented this directive through various Servicespecific documents, ranging from mandatory guidance in seeking formal Memoranda of Understanding 

to encouraging partnerships with local law enforcement agencies. The latitude in seeking agreements 

with Federal, State, and local law enforcement could, however, create gaps in the Services’ ability to 

identify DoD personnel who might pose a credible threat to themselves or others. Without strong liaison 

agreements, commanders and supervisors lack visibility of a Service member’s criminal acts committed off 

a military installation. This could impede the ability of a commander or supervisor to assess indicators that 

signal when individuals may be prone to committing violent acts or falling prey to self-radicalization.

The Services include provisions in their respective antiterrorism guidance regarding DoD requirements 

to implement effective processes to integrate and fuse all sources of available threat information from 

local, State, Federal, and host nation law enforcement agencies.

30 An exclusive focus on antiterrorism, 

however, fails to consider an escalation of violent criminal behavior. The absence of effective information 

sharing agreements creates a potentially critical void in a commander’s ability to assess his personnel.

Recommendation 2.11

Require the Military Departments and Defense Agencies to establish formal information sharing 

agreements with allied and partner agencies; Federal, State, and local law enforcement; and criminal 

investigation agencies, with clearly established standards regarding scope and timeliness.

Finding 2.12

Policies governing communicating protected health information to other persons or agencies are 

adequate at the DoD-level, though they currently exist only as interim guidance. The Services, however, 

have not updated their policies to reflect this guidance.

Discussion

Release of protected health information in the Department of Defense is governed by the Health 

Information Portability and Accountability Act (HIPAA), which balances confidentiality with the need 

to ensure operational readiness and is reflected in DoD and Service-level policy.

31 Unique guidance on 

release of medical information has been established for Restricted Reporting in cases of sexual assault.

32

29 Department of Defense. DoDD 5525.5, DoD Cooperation with Civilian Law Enforcement Officials, Washington, D.C., Jan. 15, 1986/Dec. 20, 1989, 3.

30 Department of Defense. DoDI 2000.16, DoD Antiterrorism (AT) Standards, Washington, D.C., Oct. 2, 2006/Dec. 8, 2006, 14.

31 Department of Defense. DoDI 6025.18-R, Privacy of Individually Identifiable Health Information in DoD Health Care Programs, Washington, D.C., Jan.

24, 2003, 19, 25, 49; Department of Defense. DoDI 6490.4, Requirements for Mental Health Evaluations of Members of the Armed Forces, Washington, 

D.C., Aug. 28, 1997, 7-8, 11-13, 14-15; Department of Defense. DoDD 36490.1, Mental Health Evaluations of Members of the Armed Forces, Washington, 

D.C. , Oct. 1, 1997, 5-7; Department of the Air Force. AFI 44-109, Mental Health Confidentiality and Military Law, Washington, D.C., Mar. 1, 2000, 2, 

3, 9; Department of the Army. MEDCOM Policy 09-027, Release of Protected Health Information to Unit Command Officials, Washington, D.C., May 19, 

2009, 1-5.

32 Department of Defense. DoDD 6495.01, Sexual Assault Prevention and Response Program, Washington, D.C., Oct. 6, 2005/Nov. 7, 2008, 3-4.
21

Th e Department of Defense has recently provided interim guidance that indicates the circumstances 

under which it is appropriate and required for a healthcare provider to release protected health 

information .33 Not all current Service-level guidance refl ects the most recent DoD policy .

Recommendation 2.12

Ensure Services update policies to refl ect current DoD-level guidance on the release of protected health 

information .

Finding 2.13

Commanders and military healthcare providers do not have visibility on risk indicators of Service 

members who seek care from civilian medical entities .

Discussion

Th is relates to fi nding, discussion, and recommendation 2.1.

Civilian health professionals who provide care to Service members have several sets of guidelines 

that govern response to indicators of violence that are determined during treatment . Policy does not 

require civilian providers to notify military health treatment facilities or commanders, and in some 

cases—especially when the information involves personal data—it prohibits information transfer to 

anyone except authorized family members . Th is gap in visibility prevents military medical providers, 

commanders, and supervisors from assisting the Service member or intervening until the risk indicators 

result in observable behaviors that trigger concern .

Recommendation 2.13

Consider seeking adoption of policies and procedures to ensure thorough and timely dissemination of 

relevant Service member violence risk indicators from civilian entities to command and military medical 

personnel .

Finding 2.14

Th e Department of Defense does not have a comprehensive and coordinated policy for 

counterintelligence activities in cyberspace . Th ere are numerous DoD and interagency organizations and 

offi ces involved in defense cyber activities .

Discussion

Th is relates to fi nding, discussion, and recommendation 2.1.

Th e evolving security threat increasingly involves information exchanges using the Internet . Th e Services 

have developed cyber counterintelligence programs to identify potential threats to DoD personnel, 

information, and facilities . Non-DoD agencies are also involved in cyber counterintelligence activities . 

Th e Department of Defense does not have an overarching policy coordinated across the interagency and 

with the Offi ce of the Director of National Intelligence that provides clear guidance to the Services and 

33 Department of Defense . DTM 09-006, Revising Command Notifi cation Requirements to Dispel Stigma in Providing Mental Health Care to Military 

Personnel, Washington, D .C ., July 2, 2009, 1-6 .

Chapter 2

Personnel Policies
22

Defense agencies on the execution of counterintelligence cyber activities. The Department of Defense 

is reviewing comments from the Services and appropriate defense agencies on Draft DoD Instruction 

5240.mm, Counterintelligence Activities in Cyberspace.

Recommendation 2.14

Publish policy to ensure timely counterintelligence collection, investigations, and operations in 

cyberspace for identifying potential threats to DoD personnel, information, and facilities.

Barriers or Constraints on Taking Action

Finding 2.15

DoD policy governing prohibited activities is unclear and does not provide commanders and supervisors 

the guidance and authority to act on potential threats to good order and discipline.

Discussion

This relates to finding, discussion, and recommendation 2.1.

DoD policy on prohibited activities is limited and only addresses 

active participation in groups that may pose threats to good order 

and discipline.

34 However, this does not include contacting, 

establishing, and/or maintaining relationships with persons or 

entities that interfere with or prevent the orderly accomplishment of 

the mission or present a clear danger to loyalty, discipline, mission, 

or morale of the troops.

35 All of these activities may increase an 

individual’s propensity to commit violence, and should be within the 

purview of commanders to address.

Recommendation 2.15

Review prohibited activities and recommend necessary policy changes.

Finding 2.16

Authorities governing civilian personnel are insufficient to support commanders and supervisors as they 

attempt to identify indicators of violence or take actions to prevent violence.

Discussion

This relates to finding, discussion, and recommendation 2.1.

The Department of Defense’s authorities for civilian personnel are more limited than for military 

members. For a variety of reasons, many indicators of risk factors associated with violence are not visible 

to commanders and supervisors, especially factors that might be observed outside the workplace. Even 

34 Department of Defense. DoDI 1325.06, Handling Dissident and Protest Activities Among Members of the Armed Forces, Nov. 27, 2009, 9.

35 The Supreme Court has recognized differing freedom of speech and freedom of association standards for military members and civilians. For a 

comparative discussion, see U.S. v. Brown, 45 M.J. 389, at 395 (CAAF, 1996).

DoD policy 

on prohibited 

activities is 

limited and only 

addresses active 

participation in 

groups that may 

pose threats to 

good order and 

discipline.
23

within the workplace, not all civilians are subject to some of the screening procedures that might reveal 

indicators of concern .

Th e ability to address some civilian behaviors that may be 

associated with violence is limited by DoD and Service 

policies, statutes, federal regulation, and collective bargaining 

agreements . As one example, Air Force regulations specify that 

supervisors seeking to suspend a civilian employee from the 

workplace must provide at least 24-hour notice to that employee, 

and the policies note that seven-day notice is more typical .36 

Th is authority is likely insuffi cient if an employee represents an 

imminent threat .

Recommendation 2.16

Review civilian personnel policies to determine whether 

additional authorities or policies would enhance visibility on 

indicators of possible violence and provide greater fl exibility to 

address behaviors of concern .

36 Department of Defense . DTM 09-006, Revising Command Notifi cation Requirements to Dispel Stigma in Providing Mental Health Care to Military Personnel, 

Washington, D .C ., July 2, 2009, 1-6; Department of Air Force . AFI 36-704, Discipline and Adverse Actions, Washington, D .C ., July 22, 1994, 13 .

The ability to address 

some civilian behaviors 

that may be associated 

with violence is limited 

by DoD and Service 

policies, statutes, 

federal regulation, and 

collective bargaining 

agreements. 

Chapter 2

Personnel Policies
24

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25

An impenetrable shield against all threats remains neither practical nor affordable. However, a force 

protection system that encompasses a variety of tactics, techniques procedures, and technology to deter 

and, if necessary, defeat an attack against our people has proven effective.

Our study found that some policies governing information exchange, both within the Department of 

Defense and between the Department and outside agencies, are deficient and do not support detection 

and mitigation of internal threats. There is not a well-integrated means to gather, evaluate, and 

disseminate the wide range of behavioral indicators that could signal an insider threat.

We addressed key supporting pillars such as physical security, installation access, indications and 

warning, and information sharing.

We reviewed DoD, Joint, Service, and Northern Command and its Service Components force protection 

policies and implementing guidance to determine consistency across the Department of Defense, identify 

potential best practices that could be shared/adopted, determine if there were contradictions in force 

protection policies, and identify deficiencies that, if corrected and implemented, could prevent another 

Fort Hood occurrence within the Department of Defense. In addition to DoD personnel, we contacted 

Department of Homeland Security and FBI officials to gather information, confirm policies, or to seek 

best practices.

Authorities/Command and Control

Finding 3.1

• The Department of Defense has not issued an integrating force protection policy.

• Senior DoD officials have issued DoD policy in several force protection-related subject areas such as 

antiterrorism, but these policies are not well integrated.

Discussion

Joint Publication 3-0 defines force protection as preventive measures taken to mitigate hostile actions 

against DoD personnel (to include family members), resources, facilities, and critical information.

37

Multiple senior DoD officials have responsibility for various force 

protection-related programs: Under Secretary of Defense for Personnel 

and Readiness for several law enforcement personnel and health affairs 

policies; Under Secretary of Defense for Policy for antiterrorism, 

terrorism suspicious activity reporting, continuity of operations, and 

critical infrastructure protection policies; Under Secretary of Defense 

for Acquisition, Technology, and Logistics for installation emergency 

management; and Under Secretary of Defense for Intelligence for 

physical security, military working dog, counterintelligence, use of deadly 

force, and carrying of firearms for law enforcement and security duties 

policies. No senior DoD official is assigned overall responsibility for 

force protection policy and there is no integrating DoD policy regarding 

force protection.

37 Department of Defense. Joint Publications 3-0, Joint Operations, Washington, D.C., Sep. 17, 2009.

Chapter 3

Force Protection

No senior 

DoD official is 

assigned overall 

responsibility for 

force protection 

policy and there 

is no integrating 

DoD policy 

regarding force 

protection.
26

The President has assigned the mission of force protection to the Geographic Combatant Commanders 

in the Unified Command Plan. Only one of the DoD force protection-related policies (Antiterrorism) 

addresses this mission. In DoD Directive 2000.12, DoD Antiterrorism Program, the Deputy Secretary of 

Defense assigned the Geographic Combatant Commanders tactical control for force protection for most 

DoD personnel in their geographic areas of responsibility.

38 No other DoD policy addresses this mission.

Our review suggests that there is some misunderstanding regarding the scope of the geographic 

combatant commanders’ force protection responsibility and the responsibility of the military 

departments, especially in the United States. If multiple, simultaneous events similar to the Fort 

Hood incident occur, clarity of command and control responsibilities will be essential for a rapid, 

comprehensive response.

Recommendation 3.1

• Assign a senior DoD official responsibility for integrating force protection policy throughout the 

Department.

• Clarify geographic combatant commander and military department responsibilities for force 

protection.

• Review force protection command and control relationships to ensure they are clear.

Indications and Warning

Finding 3.2

DoD force protection programs and policies are not focused on internal threats.

Discussion

This relates to finding, discussion, and recommendation 2.1.

Detecting and defeating an internal threat requires close personal observation and interaction rather than 

the construction of physical security barriers. Current DoD and Service programs that provide guidance 

concerning observation of personal behavior are primarily medically oriented and focused on suicide 

prevention. There is no formal policy guidance for commanders to identify, report, or act on indicators 

that may be indicative of an internal threat. There is no DoD-wide protocol to notify commanders 

of potential internal threats that may exist in their command. Inability to reliably detect and counter 

emerging internal threats is a gap in DoD force protection measures.

The effort to identify threats posed by those who have access to DoD installations or systems and 

knowledge of our defensive measures and weaknesses is targeted toward defending specific resources. 

Whether internal threats target a computer system, classified information, or personnel, research suggests 

they may often share common indicators.

39 The effort to identify threats may be enhanced by exploiting 

any common indicators and integrating the disparate programs designed to defend against these threats.

The Services have already cautioned their people to be alert to threats such as terrorism, school violence, 

sexual crimes, stalking, cyber crimes, domestic violence, arson, sabotage, communicated threats, and

38 Department of Defense. Unified Command Plan (UCP), Washington, D.C., Dec. 17, 2008; Department of Defense. DoDD 2000.12, 

DoD Antiterrorism (AT) Program, Washington, D.C., Aug. 18, 2003.

39 Defense Personnel Security Research Center. Technical Report 09-02: Insider Risk Evaluation and Audit, Monterey, CA, August 2009.
27

pre-attack behaviors . Several DoD programs exist (e .g ., Counterintelligence 

Awareness Training, Information Assurance Training, U .S . Army Ten Key 

Indicators of Terrorist Activity, Suicide Prevention, Personnel Reliability 

Program) that task members to report suspicious behavior indicative of future 

destructive acts .40 Th ese programs and associated training focus on protecting 

specifi c assets . Th e Department of Defense does not have a comprehensive 

training program focused on internal threats regardless of the target . In 

addition, the integration and fusion process for command, medical, law 

enforcement, and chaplain services is not fi rmly or universally established . For 

example, an installation’s Th reat Working Group could be specifi cally tasked 

to consider and evaluate internal threats as part of their normal procedure . If 

individuals of concern are brought to their attention, they could then evaluate 

and advise the commander on ways to mitigate the potential threat .

Countering the internal threat should focus on the common indicators leading up to a wide range 

of destructive events, such as terrorism, school violence, sexual crimes, stalking, cyber crimes (cyber 

stalking), domestic violence, arson, sabotage, communicated threats, and pre-attack behavior . Th is 

approach would focus on exhibited behavior regardless of the individual’s identity . New programs to 

address internal threats should take a comprehensive approach and be presented as a means to take care 

of fellow DoD members from a force protection perspective .

Training programs put in place to educate DoD personnel should be easily understandable by the entire 

population . Identifying the key indicators of aberrant behavior and clearly outlining the process to 

report will be critical to focusing the force on the threat . Establishing the process and providing the 

tools for commanders to evaluate and counter internal threats will be important as well . Predictive 

analysis for internal threats is a diffi cult proposition, but predicting and defending against external 

threats requires a similar degree of anticipation .

Th e Navy has a fusion cell designed to predict and mitigate insider violence that could serve as a 

model for the Department of Defense . Th e Naval Criminal Investigative Service established the 

Th reat Management Unit in 1996 .41 Th e Th reat Management Unit provides criminal and behavioral 

analysis and risk assessments for Navy and Marine Corps commanders to predict and mitigate potential 

violence on the part of DoD affi liated personnel . Other examples of successful threat assessment and 

intervention exist and are worthy of further study . Th e U .S . Postal Service has a successful workplace 

violence program highlighted by the use of threat assessment teams .42 Th e Association of Th reat 

Assessment Professionals provides additional resources integrating academic, private, and public studies 

and programs for countering an insider threat .43

40 Department of Defense . DoDI 5240 .6, Counterintelligence (CI) Awareness, Briefi ng, and Reporting Programs, Washington, D .C ., Aug . 7, 2004, 1-16; 

Department of Defense . DoDD 8570 .01, Information Assurance Training, Certifi cation, and Workforce Management, Washington, D .C ., Aug . 15, 2004, 

1-10; Department of the Army . Appendix A ALARACT 322, Ten Key Indicators of Potential Terrorist Associated Insider Th reats to the Army, Washington, 

D .C ., Nov . 23, 2009; Department of the Army . Army Campaign Plan for Health Promotion, Risk Reduction and Suicide Prevention (ACPHP), Washington, 

D .C ., Apr . 16, 2009; Department of Defense . DoD 5210 .42-R, Nuclear Weapons Personnel Reliability Program (PRP) Regulation, Washington, D .C ., 

Nov . 10, 2009, 1-72 .

41 Department of the Navy . Naval Criminal Investigative Service Operating Manual 3, Manual for Criminal Investigations, Chapter 29 (Assault), Paragraph 

2 .6, Th reat Management Unit, Washington, D .C ., August 2008 .

42 United States Postal Service . Washington, D .C ., May 1997 .

43 Th e Association of Th reat Assessment Professional . Th e Association of Th reat Assessment Professional (ATAP), http://www .atapworldwide .org/ .

The Department 

of Defense 

does not have a 

comprehensive 

training 

program 

focused on 

internal threats 

regardless of the 

target.

Chapter 3

Force Protection
28

Recommendation 3.2

• Develop policy and procedures to integrate the currently disparate efforts to defend DoD resources 

and people against internal threats.

• Commission a multidisciplinary group to examine and evaluate existing threat assessment programs; 

examine other branches of government for successful programs and best practices to establish 

standards, training, reporting requirements /mechanisms, and procedures for assessing predictive 

indicators relating to pending violence.

• Provide commanders with a multidisciplinary capability, based on best practices such as the Navy’s 

Threat Management Unit, the Postal Service’s “Going Postal Program,” and Stanford University’s 

workplace violence program, focused on predicting and preventing insider attacks.

Information Sharing

Finding 3.3

The Department of Defense’s commitment to support JTTFs is inadequate.

Discussion

This relates to finding, discussion, and recommendation 2.10.

Defense Criminal Investigative Service involvement at the JTTFs is not functionally managed by 

the Defense Counterintelligence and Human Intelligence Center, as is the case for the Service linked 

participants (i.e., Army Military Intelligence, Naval Criminal Investigative Service, Air Force Office of 

Special Investigations). As a result, there is no consistency of reporting from those agents back to the 

Department of Defense.

44 The lack of a single functional management structure increases the likelihood 

of confusion on the part of the FBI when it deals with DoD representatives who operate under 

different functional guidance. Any outcome should consider Defense Criminal Investigative Service 

independence and objectivity.

45

Recommendation 3.3

• Identify a single point of contact for functional management of the Department of Defense’s 

commitment to the JTTF program.

• Evaluate and revise, as appropriate, the governing memoranda of understanding between the FBI 

and different DoD entities involved with the JTTF to ensure consistent outcomes.

• Review the commitment of resources to the JTTFs and align the commitment based on priorities 

and requirements.

Finding 3.4

There is no formal guidance standardizing how to share Force Protection threat information across the 

Services or the Combatant Commands.

44 Interview with Deputy Director (DCIS) and Homeland Security/Terrorism Program Manager (DCIS). Washington, D.C., Dec. 10, 2009.

45 Department of Defense. DoDD 5106.01, Inspector General of the Department of Defense, Washington, D.C., Apr. 13, 2006.
29

Discussion

Th is relates to fi nding, discussion, and recommendation 2.10.

Policy exists stating the requirement to share threat information with the Combatant Commands .46 

When a military criminal investigative organization or a counterintelligence organization outside the 

construct of a JTTF obtains threat information pertaining to a CONUS asset or individual, there is no 

standard means to share that information with the Geographic Combatant Commands .

Th e FBI’s draft guidance for informing the Department of Defense of terrorism matters with a DoD 

nexus, does not cover who, beyond the headquarters of Service Counterintelligence organizations (Army 

G2X, Air Force Offi ce of Special Investigations, Naval Criminal Investigative Service, and the Defense 

Counterintelligence and Human Intelligence Center), should be informed of the matter . It is incumbent on 

those Headquarters elements to comply with requirements to inform the aff ected appropriate operational 

commanders or other organizations with a need to know .

Recommendation 3.4

Direct the development of standard guidance regarding how military criminal investigative organizations 

and counterintelligence organizations will inform the operational chain of command .

Finding 3.5

Th e Department of Defense does not have direct access to a force protection threat reporting system for 

suspicious incident activity reports .

Discussion

Th is relates to fi nding, discussion, and recommendation 2.10.

Suspicious Activity Reporting or Force Protection Th reat Information, as it is known to Department 

of Defense, is now an FBI nationwide initiative . Th e Department of Defense was using the Th reat and 

Location Observation Notice Program as its Suspicious Activity Reporting capability, but the program 

was terminated in September 2007 . Th is left the Department of Defense without a Suspicious Activity 

Reporting system of its own .47

Th e Deputy Secretary of Defense instructed DoD Components to submit Suspicious Incident/Activity 

Reports and other non-intelligence reporting concerning force protection threats to the FBI’s classifi ed 

Guardian Reporting System on an interim basis . DoD and FBI guidance for Guardian reporting assures 

that privacy and civil liberties are protected .48 Th is reporting continues today .

Th e FBI has created an unclassifi ed version of its Guardian system—called eGuardian—providing 

participating partners with a suspicious activity reporting system .

46 Department of Defense . DoDI 5240 .10, Counterintelligence Support to the Combatant Commands and the Defense Agencies, Washington, D .C ., May 14, 

2004; Federal Bureau of Investigation . Joint Terrorism Task Force, Standard Memorandum of Understanding Between the Federal Bureau of Investigation 

and Defense Criminal Investigation Service, Washington, D .C ., Aug . 31, 2007; Department of Defense . DoDI 5240 .6, Counterintelligence (CI) Awareness, 

Briefi ng, and Reporting Programs, Washington, D .C ., Aug . 7, 2004 .

47 Interview with Principal Analyst, OASD, Homeland Defense and America’s Security Aff airs . Washington, D .C ., Dec . 16, 2009 .

48 Department of Defense . Deputy Secretary of Defense Memorandum, Implementation of Interim Th reat Reporting Procedures, Washington, D .C ., 

Sep . 13, 2007 .

Chapter 3

Force Protection
30

eGuardian is a secure web-based system for sharing potential terrorist threats, terrorist events, and 

suspicious activity information among Federal, State, local, and tribal law enforcement partners, along 

with State fusion centers and JTTFs. eGuardian is the only Suspicious Activity Reporting system that 

communicates directly with the FBI’s JTTFs, and if adopted by the Department of Defense would 

allow designated DoD law enforcement assets access to receive and input suspicious activity. This would 

also provide an additional method by which threat information would flow from the Department of 

Defense to the FBI, in situations where the Department of Justice has an investigative interest. Adoption 

of eGuardian is currently the recommended solution being proposed by the Office of the Assistant 

Secretary of Defense for Homeland Defense for the Department of Defense.

eGuardian does not replace coordination and information sharing requirements per the 1979 Agreement 

Governing the Conduct of Defense Department Counterintelligence Activities in Conjunction with The 

Federal Bureau of Investigation and the 2009 Memorandum of Understanding between the FBI and the 

Department of Defense Governing the JTTF relationship.

Recommendation 3.5

• Adopt a common force protection threat reporting system for documenting, storing, and exchanging 

threat information related to DoD personnel, facilities, and forces in transit.

• Appoint a single Executive Agent to implement, manage, and oversee this force protection threat 

reporting system.

Finding 3.6

There are no force protection processes or procedures to share real-time event information among 

commands, installations, and components.

Discussion

This relates to finding, discussion, and recommendation 2.10.

During the initial stages of the attack at Fort Hood, commanders and first responders, unsure of the 

nature of the threat, and in an effort to maximize their security posture, set and maintained Force 

Protection Condition Delta. There were apparently no indications that the rest of CONUS DoD force 

was immediately notified of the event; most installations and units first found out about the event 

through the news media. This was a single event, but had it been the first in a series of coordinated, near 

simultaneous attacks, most other DoD installations and facilities would not have been properly postured 

for an attack. The timely sharing of incident information could have served to alert other forces within 

the Area of Responsibility to take the prepare-and-defend actions necessary to harden themselves before 

a near simultaneous attack comes to them.

The requirement for a process/system to share raw, non-validated event information in near real time is 

the key ability for alerting the force that an attack is underway. The present DoD reporting and alerting 

system, a system based on phone calls and Defense Messaging System message traffic, is neither timely 

nor able to share information simultaneously among all user levels—from tactical users to operational 

and strategic decision makers.
31

Recommendation 3.6

Evaluate the requirement for creating systems, processes, policy, and tools to share near real-time, 

unclassifi ed force protection information among military installations in CONUS to increase situational 

awareness and security response .

Access Control

Finding 3.7

DoD installation access control systems and processes do not incorporate behavioral screening strategies 

and capabilities, and are not confi gured to detect an insider threat .

Discussion

DoD policy mandates 100 percent credentials inspection for access to DoD CONUS installations .49 

Th e DoD Physical Security Program Instruction designates the Common Access Card (CAC) as “the 

principal identity credential for supporting interoperable access to installations, facilities, buildings, and 

controlled spaces .”50 While the CAC is the principal identity document, other approved documents 

may be used by dependents and other DoD affi liated individuals to obtain access . Installations outside 

CONUS may recognize other identity documents depending on status of forces agreement specifi cations . 

In all cases, however, properly credentialed individuals will be granted access to the installation .

Fort Hood is equipped with a state-of-the-art automated access control system, augmented by hands-on 

inspection of identity credentials that meet or exceed all DoD and Department of the Army guidance . 

In the case of the Fort Hood incident, the alleged perpetrator was authorized access and was a registered 

user of Phantom Express, the post’s automated access control system . Th e alleged perpetrator’s status 

as an active duty offi cer with a CAC meant that he was authorized access to virtually all military 

installations .

Detecting a trusted insider’s intention to commit a violent act requires 

observation of behavioral cues/anomalies . Th ere are Federal programs 

that train personnel to observe individuals under routine conditions . 

Authorities may engage the individual in casual conversation and 

observe their responses and behavior . When anomalies are detected, the 

individual is selected for secondary screening, which provides a greater 

opportunity to detect potential threatening activity . Th ese programs may 

be useful if employed in a similar manner by DoD security guards, police 

offi cers, supervisory personnel, persons working in visitor control centers, 

or in other common “customer service” contexts .

49 Department of Defense . DoDI 5200 .08P, Security of DoD Installation and Resources, Washington, D .C ., Dec . 17, 2008; Department of Defense . DTM 

09-012, Interim Policy Guidance for DoD Physical Access Control, Washington, D .C ., Dec . 2, 2009; Department of Homeland Security . HSPD-12, 

Policy for a Common Identifi cation Standard for Federal Employees and Contractors, Washington, D .C ., Aug . 27, 2004; National Institute of Standards 

and Technology . FIPS PUB 201-1, Federal Information Processing Standards Publication, Personal Identity Verifi cation (PIV) of Federal Employees and 

Contractors, Gaithersburg, MD, March 2006 .

50 Department of Defense . DoD 5200 .08-R, Physical Security Program: Security of DoD Installation and Resources, Washington, D .C ., May 27, 2009 .

Chapter 3

Force Protection

Detecting a 

trusted insider’s 

intention to 

commit a violent 

act requires 

observation of 

behavioral cues/

anomalies.
32

Recommendation 3.7

• Review best practices, including programs outside the U.S. Government, to determine whether 

elements of those programs could be adopted to augment access control protocols to detect persons 

who pose a threat.

• Review leading edge tools and technologies that augment physical inspection for protecting the force.

Finding 3.8

The Department of Defense does not have a policy governing privately owned weapons.

Discussion

In the absence of overarching DoD policy, the individual Services have established privately owned 

weapons policies. Service regulations direct that all personnel living in installation housing and those 

residing in common living areas (barracks) register privately owned weapons with the installation 

security office. Personnel residing in common living areas must store weapons in unit armories, and 

those weapons (and ammunition) will be inventoried at specified intervals. Those personnel residing in 

private on-base family housing may store their weapons in quarters. Service regulations for registering or 

storing privately owned weapons do not apply when living off installation.

The Services task installation commanders with establishing privately owned weapons regulations 

on their installations. The Services have established minimum standards, leaving it to commanders 

to meet installation-specific requirements, including additional guidance on transporting privately 

owned weapons. Our review conducted a representative sampling of installation policies that revealed 

prohibitions on transporting loaded firearms and transporting a firearm in the glove compartment of a 

vehicle. The guidance we reviewed also requires keeping the weapon and ammunition separate while in 

transit.

51

Recommendation 3.8

Review the need for DoD privately owned weapons policy.

Finding 3.9

Services cannot share information on personnel and vehicles registered on installations, installation 

debarment lists, and other relevant information required to screen personnel and vehicles, and grant 

access.

Discussion

This relates to finding, discussion, and recommendation 2.10.

Services, with Defense Agency support, continue to research and field advanced automated entry 

control systems designed to expedite authorized entry onto installations. However, these automated 

51 Headquarters XVIII Airborne Corps & Fort Bragg. XVIII Airborne Corps & Fort Bragg Regulation 190-12, Military Police: Privately Owned Weapons 

and Ammunition Control and Prohibited Weapons, Fort Bragg, NC, Dec. 1, 2004; Department of Defense. Combat Center Order P1630.6E, Discipline 

and Law Enforcement Regulations, Washington, D.C., Mar. 12, 1997; Department of the Navy. SUBASENLONINST 5500.1C, Privately Owned 

Weapons on Naval Submarine Base New London, Groton, CT, May 18, 2005; Department of the Air Force. AFI31-101 AAFBSUP, The Air Force 

Installation Security Program, Washington, D.C., Apr. 17, 2008; Department of the Navy. MCO 5530.14A, Marine Corps Physical Security Program 

Manual, Washington, D.C., June 5, 2009.
33

systems do not allow the Services to share information on registered users and persons debarred from 

one installation to another . Th e lack of a central authoritative database means that individuals debarred 

by a command from entering one installation for misconduct, unsuitability, or other reasons may be 

authorized access to another DoD installation .

Overseas installations do not have access to the National Crime Information Center or the Terrorist 

Screening Database . Access control systems in CONUS and overseas should be able to authenticate 

personnel against authoritative databases .

Recommendation 3.9

• Develop timely information sharing capabilities among components including vehicle registration, 

installation debarment lists, and other access control information .

• Accelerate eff orts to automate access control that will authenticate various identifi cation media 

(e .g ., passports, CAC, drivers’ licenses, license plates) against authoritative databases .

• Obtain suffi cient access to appropriate threat databases and disseminate information to local 

commanders to enable screening at CONUS and overseas installation access control points .

Chapter 3

Force Protection
34

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35

The Department of Defense must synchronize and align its emergency management program with 

national response guidance. Using common emergency management principles, we can prepare our 

military communities to respond to emergencies—from the smallest incident to the largest catastrophe. 

Our nation uses a framework and system to guide the response to any hazard.

52 These provide a 

consistent template enabling all jurisdictions and organizations across the country to prepare for, respond 

to, and recover from emergencies using a unified response. Synchronizing the Department of Defense’s 

emergency management program with this national guidance will ensure the Department can integrate 

effectively with all partners in response to any and all emergencies.

Emergency Response

Finding 4.1

Services are not fully interoperable with all military and civilian emergency management stakeholders.

Discussion

The Department of Defense guidance was promulgated in part to align the Department with national 

response policies and establish the Installation Emergency Management program.

53 The Installation 

Emergency Management program directs the Services to adopt the National Incident Management System, 

which Federal, State, and local agencies have already adopted. The Department of Defense has given the 

Services until January 13, 2011, to develop their initial capability, and until January 13, 2014, to have a full 

Installation Emergency Management program aligned with national guidance. The instruction directing 

the Services to comply with the national system directed the Services to develop their own implementation 

plans and timelines.

54 Currently all 50 states have complied with the Federal requirements. There are, 

however, no measures or established milestones in DoD guidance to define initial and full capability.

The Department of Defense will experience challenges in reaching full capability in the absence of 

centralized policy because of synchronization and funding issues. Technical capabilities such as 911/

dispatch, mass notification, information sharing, and Common Operating Picture could delay full 

capability because of the cost of some systems.

The Installation Emergency Management program identifies how first responders from on and off the 

installation integrate into a unified effort during emergency response and recovery operations. This 

Installation Emergency Management plan is designed to become the installation’s umbrella plan, which 

nests functional area plans, thus enhancing coordination between responders.

Until full operational capability is achieved, integration between installation and facility emergency 

personnel and other first responders will continue to be largely based on personal relationships rather 

than on codified procedures.

52 Department of Homeland Security. National Response Framework, Washington, D.C., Jan. 2008, 1-12. Department of Homeland Security. National 

Incident Management System, Washington, D.C., December 2008, 45-62.

53 Department of Defense. DoDI 6055.17, DoD Installation Emergency Management Program, Washington, D.C., Jan. 13, 2009, 2.

54 Ibid.

Chapter 4

Emergency Response and Mass Casualty
36

Current Air Force guidance55 puts the Air Force ahead of schedule for achieving full compliance with the 

Installation Emergency Management program. Reviews of the Air Force approach suggest possible best 

practices for consideration by other Services.

Recommendation 4.1

• Establish milestones for reaching full compliance with the Installation Emergency Management

program.

• Assess the potential for accelerating the timeline for compliance with the Installation Emergency 

Management program.

Implementation of Enhanced 911

Finding 4.2

There is no DoD policy implementing public law for a 911 capability on DoD installations.

56 Failure to implement 

policy will deny the military community the same level of emergency response as those communities off base.

Discussion

Rapid communications, particularly major communication nodes such as 911 Dispatch Centers, are 

critical in an emergency response. Congress mandated Enhanced 911 services as the national standard 

but it has not been fully implemented by the Department of Defense.

57

Our review identified the following deficiencies:

• 911 is not the universal emergency assistance number on DoD installations

• Not all installations have enhanced 911 capability

• Some installations have 911 calls going on and off the installation to different dispatch centers 

depending upon what type of phone is used (e.g., cell phones, Defense Switching Network phones)

While no major 911 delays were identified in the Fort Hood After Action Review (AAR),58 911 calls 

from cell phones and family housing were routed through the Bell County Emergency Dispatch 

Center, which had to relay the information verbally to the Fort Hood Dispatch center. Fort Hood then 

dispatched first responders to the incident. Calls from on base59 telephones went directly to the Fort 

Hood Dispatch Center. Since Fort Hood does not have Enhanced 911 capability, the caller’s location 

and information was not available. Had callers from cell phones and family housing wanted to reach the 

Fort Hood Dispatch Center directly, they would have had to use a phone number other than 911.

55 Department of the Air Force. AFI 10-2501, Air Force Emergency Management Program Planning and Operations, Washington, D.C., Apr. 6, 2009; 

Department of the Air Force. AF Manual 10-2504, Air Force Incident Management for Major Accidents and Disasters, Washington, D.C., Dec. 1, 2009; 

Department of the Air Force. AF Manual 10-2502, Air Force Incident Management System Standards and Procedures, Washington, D.C., Sep. 25, 2009.

56 Public Law. 106-81, Wireless Communications and Public Safety Act of 1999, Washington, D.C., Oct. 26, 1999; Public Law. 108-494, Enhance 911 

Services. Washington, D.C., Dec. 23, 2004.

57 Public Law. 108-494, Enhance 911 Services, Washington, D.C., Dec. 23, 2004, Section 102 Findings, Section 102; The law incorporates state-of-the-art 

telecommunications capabilities to 911 systems.

58 HQ III Corps and Fort Hood. Fort Hood After Action Review, Fort Hood, TX, November 5, 2009, Slide 22.

59 For the purpose of this report we consider “on base” to mean calls made on Defense Switching Network (DSN). Calls from DSN go directly to the Fort 

Hood Department Emergency Services Dispatch.
37

By having the Department of Defense implement Enhanced 911 services policy, dispatch centers would 

have access to vital information about a caller’s location and identifi cation in case the call is lost, or if the 

caller becomes incapacitated . This capability would also help reduce response times and increase 

coordination among all responders . Failure to implement policy will deny the military community the 

same level of emergency response as those communities off base .

Recommendation 4.2

Develop policy that provides implementation guidance for Enhanced 911 services in accordance with 

applicable laws .60

Law Enforcement Practices–Active Shooter Threat

Finding 4.3

DoD policy does not currently take advantage of successful models for active shooter response for 

civilian and military law enforcement on DoD installations and facilities .

Discussion

Th is review identifi ed tactics, techniques, and procedures that exist within the civilian community to 

respond to the active shooter scenario . An active shooter is generally described as an individual(s) actively 

engaged in killing people in a confi ned and populated area . Typically 

there is no pattern or method to their selection of victims .61 Unfortunately, 

no DoD policy exists for active shooter scenarios, and the Department 

of Defense has no established process to quickly adopt civilian law 

enforcement best practices .

Current active shooter response protocols came out of the Columbine 

tragedy, which transformed police procedures and tactics for dealing with 

shooting rampages . Prior to Columbine the tactic was to isolate and call in 

a special response team .62 After Columbine, police departments collectively 

developed new active shooter response protocols with the goal being to 

neutralize the threat immediately . Th e Fort Hood AAR63 noted that the 

installation’s Department of Emergency Services began training this new 

active shooter response protocol last year and during this incident the 

responding offi cers attributed their actions to this new training protocol .64

60 Public Law . 106-81, Wireless Communications and Public Safety Act of 1999, Washington, D .C ., Oct . 26, 1999; Public Law . 108-494, Enhance 911 

Services, Washington, D .C ., Dec . 23, 2004 .

61 Department of Homeland Security . Active Shooter: How to Respond, Washington, D .C ., 2008, 7 .

62 Marine Corps Police Academy . Lesson Plan 9 .2, Active Shooter, October 2008, 8; Marine Corps Police Academy . Study Guide 9 .2, Active Shooter,

October 2008, 5 .

63 HQ III Corps and Fort Hood . Fort Hood After Action Review, Fort Hood, TX, Nov . 5, 2009, Slide 23 .

64 Police Offi cer Sgt . Kimberly Munley was trained through Advanced Law Enforcement Rapid Response Training (A .L .E .R .R .T .) which equips fi rst 

responders with tactical skills and training on how to stop active shooters; Davis, Bianca . First Responder: Offi cer who ended massacre trained by Texas 

State program, Nov . 10, 2009 . http://star .txstate .edu/content/fi rst-responder-offi cer-who-ended-massacre-trained-texas-state-program, (accessed Dec . 10, 

2009) .

Chapter 4

Emergency Response and Mass Casualty

Despite the 

absence of DoD 

guidance, the 

Services have 

included the 

active shooter 

protocol in their 

civilian police 

training.
38

The Secretary of the Army is the Executive Agent charged with developing minimum training standards 

for civilian police and security guard training.

65 However, the current minimum standards do not 

include active shooter response protocols. Despite the absence of DoD guidance, the Services have 

included the active shooter protocol in their civilian police training.

66 It is not, however, included in the 

training for military law enforcement members.

The Air Force has included guidance on this particular topic in AFI 31-201, Security Forces Standards 

and Procedures.67 In this instruction, the response to an active shooter threat is specifically addressed as 

a command responsibility, and requires that active shooter protocols be incorporated into installation 

plans. This is by far the most comprehensive direction in published Service policies, and could be 

considered a best practice.

While the Fort Hood AAR does not address the actions of the victims and other bystanders during the 

assault this is an area that requires examination. Typically, individuals involved in these situations have 

never considered how to react under these circumstances, including how to react when law enforcement 

officers arrive on the scene. There are a variety of training tools available that address employee responses 

during workplace violence situations. The Department of Homeland Security publishes a pamphlet 

which provides basic training and awareness of appropriate actions people can and should take during 

this type of threat.

68 The Department of Defense has no equivalent training tool. It could, however, 

be incorporated into an existing personal security training program such as that found in the Level 1 

Antiterrorism Awareness annual training requirement.

69

Recommendation 4.3

• Identify and incorporate civilian law enforcement best practices, to include response to the active 

shooter threat, into training certifications for civilian police and security guards.

• Include military law enforcement in the development of minimum training standards to ensure 

standard law enforcement practices throughout the Department of Defense.

• Incorporate the Department of Homeland Security best practices regarding workplace violence and 

active shooter awareness training into existing personal security awareness training contained in 

current Level 1 Antiterrorism Awareness training.

70

• Develop a case study based on the Fort Hood incident to be used in installation commander 

development and on-scene commander response programs.

65 Department of Defense. DoDI 5210.90, Minimum Training, Certification, and Physical Fitness Standards for Civilian Police and Security Guards in the 

Department of Defense, Washington, D.C., July 9, 2007; Department of Defense. Deputy Assistant Secretary of Defense Memorandum, Designation of 

the Secretary of the Army as the DoD Executive Agent for Training, Certification, and Physical Fitness Standards for DoD Civilian Police Officers and Security 

Guards, Washington, D.C., Jan. 4, 2006.

66 In some instances it is identified in specific tactics, techniques, and procedures, such as the Navy’s Law Enforcement And Physical Security For Navy 

Installations publication; Department of the Navy. NTTP 3-07.2.3, Law Enforcement and Physical Security for Navy Installations, Washington, D.C., 

June 2009, 5-4 – 5-7.

67 Department of the Air Force. AFI 31-201, Security Forces Standards and Procedures, Washington, D.C., Mar. 30, 2009, 31; High Risk situations in 

Chapter 9 states “Security Forces must take immediate action to neutralize the threat.” Further, it requires that “Installation plans...must address the 

use of Security Forces to isolate, contain, and neutralize a terrorist, active shooter, or hostage incident, with or without assistance.”

68 Department of Homeland Security. Active Shooter: How to Respond, Washington, D.C., 2008, 1-20.

69 Department of Defense. DoDI 2000.16, DoD Antiterrorism Standards, Washington, D.C., Oct. 2, 2006.

70 Ibid.
39

Mass Warning and Notifi cation

Finding 4.4

Based on Joint Staff Integrated Vulnerability Assessments, many DoD installations lack mass notifi cation 

capabilities .

Discussion

DoD Instruction 6055 .17 on Installation Emergency Management directs all installation commanders to 

“develop mass warning and notifi cation capabilities with the ability to warn all personnel within 10 minutes of 

incident notifi cation at the dispatch center .”71 DoD Antiterrorism Standards also require that mass notifi cation 

systems be incorporated into emergency response planning .72 Th e specifi c standards, requirements, and 

applications for all mass notifi cation systems are contained in the Unifi ed Facilities Criteria .73

At Fort Hood the emergency operations center eff ectively used their “Big Voice” system as part of their 

response protocol during the incident . As mentioned in the AAR:

Soldiers were notifi ed through loud speaker to return to their units for accountability and to 

advise the Post of the situation and to issue instructions. Use of the Big Voice prevented a lot of 

phone calls into the Emergency Operations Center for basic information.74

Big Voice (Giant Voice) has been the standard for mass notifi cation on DoD installations . Today, a more 

comprehensive approach to mass warning using newer technologies is available, such as the Navy’s Wide Area 

Alert and Notifi cation System . It includes Automatic Telephone Notifi cation System and Computer Desktop 

Notifi cation System capabilities .75 Th ese capabilities could be coupled with other personal computing devices 

such as PDAs, text messaging to cell phones, and social networking sites such as Twitter and Facebook . Th ese 

new technologies have been put to use at numerous universities since the Virginia Tech mass shooting .76

Recommendation 4.4

Examine the feasibility of advancing the procurement and deployment of state-of-the-art mass warning 

systems and incorporate these technologies into emergency response plans .

Common Operational Picture

Finding 4.5

Services have not widely deployed or integrated a Common Operational Picture capability into 

installation Emergency Operations Centers per DoD direction .77

72 Department of Defense . DoDI 6055 .17, DoD Installation Emergency Management Program, Washington, D .C ., Jan . 13, 2009, 32 .

72 Department of Defense . DoDI 2000 .16, DoD Antiterrorism Standards, Washington, D .C ., Oct . 2, 2006, 24 .

73 Unifi ed Facilities Criteria 4-021-01, Design and O&M: Mass Notifi cation Systems, Dec . 18, 2002 .

74 HQ III Corps and Fort Hood . Fort Hood After Action Review, Fort Hood, TX, Nov . 5, 2009, Slide 49 .

75 Department of the Navy . Draft CNIC Instruction 2000 .XX, CNIC Wide Area Alert Network, Unpublishd, Paragraph 5 .0, System Operational 

Requirements .

76 Robin Hattersly Gray . Virginia Tech 1 Year Later: How Campuses Have Responded, March/April 2008, http://www .campussafetymagazine .com/

Articles/?ArticleID=157, (accessed Dec . 8, 2009) .

77 Department of Defense . DoDI 6055 .17, DoD Installation Emergency Management Program, Washington, D .C ., Jan . 13, 2009, 31, 39 .

Chapter 4

Emergency Response and Mass Casualty
40

Discussion

Information sharing and establishing a Common Operational Picture is vital to coordinating efforts 

of multiple emergency response agencies’ and facilitates’ collaborative planning at all echelons to 

achieve situational awareness. A Common Operational Picture is “a single identical display of relevant 

information shared by more than one command.”78 A Common Operational Picture provides a 

standardized, continuously updated, multiple-user capability to produce reports, mapping, imagery, and 

real time information sharing between multiple subscribers.

DoD guidance directs installations to have a well-defined communication plan with personnel engaged 

in emergency response, as well as with local first responders. This plan includes a Common Operational 

Picture and information management system to execute and support actions listed in the Installation 

Emergency Management Plan and to ensure interoperable communications with civil authorities.

While the Fort Hood AAR is correct in stating that “information sharing and establishing a Common 

Operational Picture is best conducted at Ops Center,”79 installation personnel experienced challenges 

as they attempted to integrate multiple Emergency Operations Centers and establish a Common 

Operational Picture. At Fort Hood multiple reports of gun shots caused commanders to delay the 

release of children from the local day care center for six hours due to the lack of situational awareness 

and communication with on-post organizations.

80

As the Services deploy this capability, there are current technologies that have been adopted by 

emergency management organizations across the country such as WebEOC and E-Team. Services need 

to integrate their Common Operational Picture with technologies used by local community.

Recommendation 4.5

• Examine the feasibility of accelerating the deployment of a state-of-the-art Common Operational 

Picture to support Installation Emergency Operations Centers.

• Develop an operational approach that raises the Force Protection Condition in response to a 

scenario appropriately and returns to normal while considering both the nature of the threat and the 

implications for force recovery and healthcare readiness in the aftermath of the incident.

Synchronization of Emergency Management 

Policies and Programs

Finding 4.6

• Stakeholders in the DoD Installation Emergency Management program, including the Under 

Secretary of Defense for Policy; Under Secretary for Personnel and Readiness; Under Secretary 

of Defense for Intelligence; Under Secretary of Defense for Acquisition, Technology & Logistics; 

Assistant Secretary of Defense for Public Affairs; and Assistant Secretary of Defense for Networks 

and Information Integration/Chief Information Officer, have not yet synchronized their applicable 

programs, policies, processes, and procedures.

79 Department of Defense. Joint Publication 1-02, DoD Dictionary of Military and Associated Terms, October 2009, 105.

79 HQ III Corps and Fort Hood. Fort Hood After Action Review, Fort Hood, TX, Nov. 5, 2009, Slides 46, 48, 51.

80 HQ III Corps and Fort Hood. Fort Hood After Action Review, Fort Hood, TX, Nov. 5, 2009, Slides 11, 65, 70, 74.
41

• Better synchronization and coordination would remove redundant planning requirements, identify 

seams in policy, focus programmed resources, and streamline procedures to achieve unity of eff ort in 

installation emergency management .

Discussion

Th e Under Secretary of Defense for Acquisition, Technology & Logistics coordinates DoD programs, 

policies, processes, and procedures . Several policy documents require installations to develop emergency 

response and recovery plans related to mass casualty incidents (i .e ., disaster plans, antiterrorism plans, 

emergency response Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) plans, mass 

disaster, or mass casualty response plans) . Th ese stove-piped requirements are embedded within Installation 

Emergency Management functional area policies such as: fi re, antiterrorism, CBRNE, medical, religious 

support, and casualty aff airs .81 If DoD guidance was better synchronized, these redundant planning 

requirements could be identifi ed and consolidated . A good example of synchronizing Emergency 

Management guidance is the Assistant Secretary of Defense for Health Aff airs policy for Public Health 

Emergency Management82 which requires installation medical treatment facility emergency plans to be 

integrated with the installation emergency management plan . Better coordination of policy and procedures 

in this way would lead to the Installation Emergency Management plan becoming the umbrella plan for 

emergency response and recovery, nesting within it functional area plans in a synchronized manner .

Recommendation 4.6

• Review responsibilities for synchronizing Offi ce of the Secretary of Defense programs, policies, and 

procedures related to installation emergency management .

• Establish policy requiring internal synchronizing of installation programs, plans, and response for 

emergency management .

Mutual Aid Agreement

Finding 4.7

Mutual Aid Agreements (MAAs) between DoD and civilian 

support agencies across the Services are not current .

Discussion

CONUS military installations and their surrounding civilian 

communities are increasingly interdependent . When an emergency 

or a disaster strikes, it is critical for both parties to rely on 

established relationships for mutual support . Coordination is 

normally formalized in mutual aid agreements to meet response requirements following a disaster . 

81 Department of Defense . DoDI 6055 .06, DoD Fire and Emergency Services Program, Washington, D .C ., Dec . 21, 2006, 22; Department of Defense . 

DoDI 2000 .16, DoD Antiterrorism Standards, Washington, D .C ., Oct . 2, 2006, 17; Department of Defense . DoDI 2000 .18, DoD Installation CBRNE 

Response Guidelines, Washington, D .C ., Dec . 4, 2002, 14; Department of Defense . DoDI 1300 .18, DoD Personnel Casualty Matters, Policies and 

Procedures, Washington, D .C ., Jan . 8, 2008, 8; Department of Defense . DoDI 6055 .17, DoD Installation Emergency Management Program, Washington, 

D .C ., Jan . 13, 2009 .

82 Department of Defense . Draft DoDI 6200 .03, Public Health Emergency Management Within the Department of Defense, Washington, D .C ., Unpublished, 

23; Th is policy requires a Medical Emergency Manager be appointed as each installation medical treatment facility to serve as the primary point of 

contact with the Installation Emergency Manager and ensure medical treatment facility emergency management plans are integrated and compliant with 

Installation Emergency Management program .

Chapter 4

Emergency Response and Mass Casualty

CONUS military 

installations and 

their surrounding 

civilian communities 

are increasingly 

interdependent.
42

Within the medical function area, Department of Defense guidance83 requires military treatment facilities 

to meet or exceed the accreditation standards of The Joint Commission (TJC)84 and to comply with all 

related management programs.

Ample policy exists across the Department of Defense and Service levels regarding the need to develop 

and maintain MAAs.

85 Historically those agreements have not been maintained or exercised sufficiently. 

Functional areas, including fire, engineering, medical, and religious support have relied on MAAs 

to resolve resource gaps and share capabilities for daily operations and emergencies. To comply with 

TJC’s accreditation standards, hospitals must incorporate robust emergency management planning and 

coordination. The 12 TJC Emergency Management standards, including 111 Elements of Performance 

require Medical Emergency Management Planning, coordination, and exercising with local agencies 

including installation as well as civilian stakeholders. In addition, DoD guidance requires all tenants to 

participate in Installation Emergency Management planning and all-hazards exercises.

86

Existing DoD and Service emergency management-related guidance recognizes the need for interagency 

coordination of agreements to resolve resource gaps that are identified during planning or real world 

events. Our review, however, found no overarching guidance regarding the maintenance, frequency of 

review, and tracking of MAAs. The exceptions are guidance for agreements to have legal review87 and to 

be signed by a responsible official.

88

The Fort Hood experience highlighted that MAAs were in place, and were helpful in meeting the emergency 

response requirements. They had not, however, been tracked and were not exercised sufficiently to ensure 

currency and effectiveness. This resulted in delays in the installation obtaining information on patients taken 

to civilian hospitals.

89 Although liaison officers were deployed to assist in obtaining patient information, 

prior coordination and planning might have facilitated the free flow of information between the civilian 

hospitals and the installation. As mentioned in our earlier discussion of information sharing, restrictions on 

what constitutes releasable information under HIPAA and other guidelines further complicate matters in an 

emergency response scenario. Also, if the agreements had been included in exercises extending past immediate 

response into consequence management, the shortcoming in information sharing may have been identified.

The Fort Hood incident highlights the value of exercising and practicing response plans with local 

entities. Maintaining current MAAs and involving civilian hospitals in disaster plan response exercises 

could enhance the availability of information concerning military patients through military treatment 

83 Department of Defense. DoDD 6025.13, Medical Quality Assurance in the Military Health System, Washington, D.C., May 4, 2004.

84 As of Jan. 1, 2007 the JCAHO changed its name to The Joint Commission. The Joint Commission. A Journey Through the History of The Joint 

Commission. http://www.jointcommission.org/aboutus/joint_commission_history.htm, (accessed Dec. 9, 2009).

85 Department of the Army. AR 525-27, Army Emergency Management Program, Washington, D.C., Dec. 4, 2008, 5; Department of the Navy. BUMED 

Instruction 3440.10, Navy Medicine Force Health Protection Emergency Management Program, Washington, D.C., Nov. 20, 2008, encl. 1, 26; 

Department of Defense. DoDI 6055.17, DoD Installation Emergency Management Program, Washington, D.C., Jan. 13, 2009; Department of Defense.

DoDI 2000.18, DoD Installation CBRNE Response Guidelines, Washington, D.C., Dec. 4, 2002; Department of the Navy. OPNAV Instruction 

3440.17, Navy Installation Emergency Management Program, Washington, D.C., July 22, 2005, 4; Department of the Air Force. AF Manual 32-4004,

Emergency Response Operations, Washington, D.C., Dec. 1, 1995, 22; Department of the Navy. Draft MCO 3440.9, Marine Corps Installation Emergency 

Management Program, Washington, D.C., Unpublished, 3, 7; Department of the Air Force. AFI 32-2001, Fire Emergency Services Program, Washington, 

86 Department of Defense. DoDI 6055.17, Installation Emergency Management Program Washington, D.C., Jan. 13, 2009.

87 Department of Defense. DoDI 2000.18, DoD Installation CBRNE Response Guidelines, Washington, D.C., Dec. 4, 2002; Department of the Army.

AR 600-20, Army Command Policy, Washington, D.C., Mar. 18, 2008.

88 Department of Defense. DoDI 2000.18, DoD Installation CBRNE Response Guidelines, Washington, D.C., Dec. 4, 2002.

89 HQ III Corps and Fort Hood. Fort Hood After Action Review, Fort Hood, TX, Nov. 5, 2009, Slides 35, 38.
43

facilities to commanders . Currently, most exercises are not 

resourced to extend the scenario beyond hospital emergency 

departments, leaving gaps in inter-hospital administration 

process coordination . Th e Fort Hood incident highlights 

the importance of extending exercises beyond the immediate 

response to consequence management to include local agencies .

Recommendation 4.7

Review Installation Emergency Management programs to 

ensure correct guidance on integrating tracking, exercising, 

and inspections of MAAs .

Emergency Family Assistance

Finding 4.8

Th e Department of Defense has not produced guidance to develop family assistance plans for mass 

casualty and crisis response . As a result, Service-level planning lacks consistency and specifi city, which 

leads to variation in the delivery of victim and family care .

Discussion

Following the September 11, 2001, attacks, the Department of Defense established a joint military 

Services Pentagon Family Assistance Center . Th e Pentagon Family Assistance Center AAR cited a 

lack of DoD policy guidance for victim and family support services plans .90 Th ese plans, as part of 

the overall emergency response, would have improved communication and coordination and reduced 

the response time to organize operations during the aftermath of September 11 . Th e Pentagon 

AAR identifi ed a requirement for synchronizing and coordinating the following 13 functional areas: 

administration, casualty and mortuary assistance, child care, command and control, communications 

and information technology, community outreach (i .e ., medical, mental health, chaplain), donations 

management, legal assistance, logistics and operational support, public aff airs, resource management, 

security, and staff and volunteer management .91

Our review of DoD publications revealed that the lessons from the terrorist attacks in 2001 resulted in 

suffi cient policy guidance for implementing day-to-day family support programs and baseline family support 

services . However, this guidance has not been updated nor does it clearly delineate a specifi c structure for how 

these services come together and integrate in support of a crisis or mass casualty incident .92

Th e Services have policies that guide family assistance and support services .93 A review of these policies 

noted they do not consistently diff erentiate between services off ered routinely and those required in

90 Department of Defense . Pentagon Family Assistance Center After Action Report, Washington, D .C ., March 2003 .

91 Ibid .

92 Department of Defense . DoDD 1342 .17, Family Policy, Washington, D .C ., Nov . 21, 2003, 1-6; Department of Defense . DoDI 1342 .22, Family Centers,

Washington, D .C ., Dec . 30, 1992, 7-8 .

93 Department of the Army . AR 608-1, Army Community Services Center, Washington, D .C ., Sept . 19, 2007, Chapter 4-1, 9, Chapter 4-2, 9-10, Chapter 

4-4, 10; Department of the Navy . OPNAV Instruction 1754 .1B, Fleet and Family Support Center Program, Washington, D .C ., Nov . 5, 2007, 8; 

Department of the Navy . MCO P1700 .24B, Marine Corps Personal Services Manual, Washington, D .C ., Dec . 27, 2001, 2-3; Department of the Air 

Force . AFI 36-3009, Airman and Family Readiness Centers, Washington, D .C ., Jan . 18, 2008, 1-17 .

The Fort Hood incident 

highlights the importance 

of extending exercises 

beyond the immediate 

response to consequence 

management to include 

local agencies.

Chapter 4

Emergency Response and Mass Casualty
44

response to a crisis or mass casualty incident. The exception is the Air Force which incorporated the 

Pentagon AAR recommendations into its policy. This policy and the companion “Tool Kit” specify 

unique mission responsibilities and resourcing requirements needed to integrate victim and family 

services in response to the full spectrum of crises or catastrophic events.

94

The Services did not consistently implement the guidance from the Pentagon AAR recommendations. 

The Fort Hood AAR again identified the need for planning for emergency family assistance.

95 This 

AAR cited instances related to family service and support functions that would have been improved with 

prior planning, to include donation management, family reception, escort functions, chaplain support, 

and casualty assistance.

96 As part of the installation’s response to the tragic events in November, leaders 

developed the Fort Hood Behavioral Health Campaign Plan that offers a framework for providing 

physical, emotional, and spiritual care to those affected by a mass casualty or disaster event.

97 The three 

core elements identified in the Campaign Plan are among the 13 identified in the Pentagon AAR.

Recommendation 4.8

• Develop guidance incorporating the core service elements of a Family Assistance Center as identified 

in the Pentagon AAR.

• Develop implementation guidance to establish requirements for a Family Assistance Center crisis and 

mass casualty response as integral components of Installation Emergency Management plans.

• Consider the Air Force’s Emergency Family Assistance Control Center and the Fort Hood 

Behavioral Health Campaign Plan as possible best practices when developing policy.

Religious Support Integration

Finding 4.9

The lack of published guidance for religious support in mass casualty incidents hampers integration of 

religious support to installation emergency management plans.

Discussion

Our review of DoD guidance found no instructions that address religious support planning and 

integration requirements in response to a mass casualty incident. This results in inconsistencies in 

Service policies on integrating religious support into emergency management, and could lead to 

inadequate planning and coordination for religious support resources.

Service policies regarding religious support differs among the Services. In the Navy and Marine Corps, 

the integration of religious support in a mass casualty incident is a base and installation decision. The 

Marine Corps has a publication that provides crisis ministry guidance.

98 Other than the Army Medical 

94 Airman and Family Readiness Center. Emergency Family Assistance Control Center Tool Kit, May 2007.

95 HQ III Corps and Fort Hood. Fort Hood After Action Review, Fort Hood, TX, Nov. 5, 2009, Slides 81-89.

96 Fort Hood After Action Review; Presentation at Fort Hood, TX, Dec. 8, 2009, Slides 81-89.

97 HQ III Corps and Fort Hood. Fort Hood Behavioral Health Campaign 09-11-665, Fort Hood, TX, Dec. 7, 2009.

98 U.S. Marine Corps. MCRP 6-12A, Religious Ministry Team Handbook, Quantico, VA, May 16, 2003, 5-1, 5-9.
45

Command’s regional Special Medical Augmentation Response Teams,99 which includes religious 

support specialists who provide religious support during mass casualty and crisis incidents, there is no 

overarching Army guidance . Lastly, Air Force instructions100 designate the chaplain as a formal member 

of the installation emergency management planning team, the Critical Incident Stress Management 

Team, the Disaster Response Force,101 and the Disaster Response Team .102 Th e Air Force guidance may 

be a best practice for consideration in developing DoD policy .

Inconsistencies in DoD policy and Service guidance were illustrated during the Fort Hood incident . 

When the incident began, the Installation Chaplain was not contacted immediately .103 As a result, there 

was a delay in the Chaplain’s response to the immediate needs of victims and responders .

Recommendation 4.9

• Consider modifying DoD and Service programs designed to promote, maintain, or restore health 

and well-being to off er each person the services of a chaplain or religious ministry professional .

• Develop policy for religious support in response to mass casualty incidents and integrate guidance 

with the Installation Emergency Management Program .

Finding 4.10

Inconsistencies among Service entry level chaplain training programs can result in inadequate 

preparation of new chaplains to provide religious support during a mass casualty incident .

Discussion

Th e Services train chaplains in emergency and mass casualty response . However, they provide this 

training at diff erent times .

Th e Navy’s Chaplain Basic Course provides no formal training in religious support to mass casualty 

incidents, but upon arrival at their fi rst Navy or Marine Corps duty station, Navy chaplains receive 

formal instruction in accordance with base or ship emergency management plans .

Air Force chaplains receive mass casualty familiarization training at their Basic Course and then receive 

more detailed mass casualty training and participate in Major Accident Response Exercises upon arriving 

at their fi rst duty station .

Th e Army Chaplain Basic Course includes comprehensive training for religious support during mass 

casualty incidents . Th is instructional program is a possible best practice for other Services to consider . 

99 A current Army manual provides for pastoral care to the sick or wounded; speaks to religious support in the context of Defense Support to Civilian 

 (DSCA) authority; establishes UMTs as members of interdisciplinary case management teams and hospital committees; and expresses what UMTs do 

 in the MASCAL and trauma response realm; Department of the Army . FM 1-05, Religious Support, Washington, D .C ., Apr . 18, 2003, 2-10 .

100 Department of the Air Force . AFI 34-1101, Assistance of Survivors of Persons Killed in Air Force Aviation Mishaps and Other Incidents, Washington, D .C ., 

 Oct . 1, 2001, 20; Air Force Emergency Management Program Planning and Operations, 128-129, 145 .

101 Department of the Air Force . AFI 34-1101, Assistance of Survivors of Persons Killed in Air Force Aviation Mishaps and Other Incidents, Washington, D .C ., 

 Oct . 1, 2001, 20 .

102 Department of the Air Force . AFI 52-104, Chaplain Services Readiness, Washington, D .C ., Apr . 26, 2006, 74-75 .

103 Installation Chaplain’s presentation at Fort Hood, TX, Dec . 8, 2009 .

Chapter 4

Emergency Response and Mass Casualty
46

The Army also conducts an Emergency Medical Ministry Course that is open to Religious Support 

Teams from all Services to enhance counseling and care skills for traumatic situations.

104

The Fort Hood Installation Chaplain noted that three new chaplains performed exceptionally well 

during the November 5, 2009, mass casualty, and he credited their success to the training they received 

at the Chaplain Basic Course.

105

Recommendation 4.10

Review mass casualty incident response training in the Chaplain Basic Officer Courses.

Memorial Service Support

Finding 4.11

The Department of Defense has not yet published guidance regarding installation or unit memorial 

service entitlements based on the new Congressional authorization to ensure uniform application 

throughout the Department.

Discussion

Congress established a new entitlement that authorizes travel and transportation to specific family 

members to attend a memorial service in honor of a deceased service member.

106 To implement these 

new entitlements DoD guidance is necessary to ensure that they are consistently applied across the 

Services. Commanders must understand which family members are entitled to funded travel, the 

time allowed for travel, and any restrictions that may apply. In joint basing, consistent application 

will be significant when considering the likelihood that members of different Services could become 

fatalities in the same event.

The Fort Hood incident highlighted the need for this policy. In an effort to support the families of the 

fallen, the Army requested travel entitlements based on the recent Congressional authorization. Since 

implementing guidance had not been published, the Army obtained DoD authorization for government 

funded travel for eligible family members to attend the Fort Hood Memorial Ceremony.

Recommendation 4.11

Develop standardized policy guidance on memorial service entitlements.

104 The Emergency Medical Ministry Course is a two-week, intensive course suitable for all Service Religious Support Teams.

105 Presentation at Fort Hood, TX, Dec. 8, 2009.

106 National Defense Authorization Act for FY 2010. Public Law 111-84, Section 631, Travel and Transportation for Survivors of Deceased Members of the 

Uniformed Services to Attend Memorial Services, Washington, D.C., Oct. 30, 2009.
47

Private Citizens with No DoD Affi liation

Finding 4.12

• DoD casualty aff airs policy,107 Federal law,108 and DoD mortuary aff airs guidance109 do not exist 

regarding injury or death of a private citizen with no DoD affi liation on a military installation 

within CONUS .

• Th ere is no prescribed process to identify lead agencies for casualty notifi cation and assistance or to 

provide care for the deceased, resulting in each case being handled in an ad-hoc manner .

Discussion

At Fort Hood, one of the fatalities was a DoD contract employee . Upon review, it became apparent 

that the death of a private citizen in these circumstances would have presented a situation without clear 

guidance as to notifi cation policy and the provision of casualty assistance . Th is review expanded this 

incident to include all private citizens who frequent military installations .

Our review of DoD and service casualty policies revealed no guidance, at any level, that was suffi cient 

to address the full range of issues pertaining to private citizens who become casualties on a CONUS 

military installation .110 In the area of DoD and Service mortuary aff airs policies, this review revealed a 

similar absence of guidance regarding mortuary entitlements and services .111

Recommendation 4.12

• Review current policies regarding casualty reporting and assistance to the survivors of a private 

citizen with no DoD affi liation, who is injured or dies on a military installation within CONUS .

• Review current mortuary aff airs policies relating to mortuary services for private citizens who 

become fatalities on a military installation within CONUS .

107 Department of Defense . DoDD 1300 .18, Department of Defense (DoD) Personnel Casualty Matters, Policies, and Procedures, Aug . 14, 2009, 1-62 .

108 Federal Law . Title 5, United States Code, Section 5742, Transportation of Remains, Dependents and Eff ects; Death Accuring Away From Installation or 

 Abroad, Washington, D .C ., Jan . 5, 2009 .

109 Department of Defense . DoDD 1300 .22, Mortuary Aff airs Policy, Feb . 3, 2000, 1-10 .

110 Department of Defense . DoDD 1300 .18, Department of Defense (DoD) Personnel Casualty Matters, Policies, and Procedures, Aug . 14, 2009, 13-15 . 

 Department of the Army . AR 600-8-1, Army Casualty Program, Washington, D .C ., Apr . 30, 2007, 3-11; Department of the Navy . MCO P3040 .4E, 

Marine Corps Casualty Procdecures Manual, Washington, D .C ., Feb . 27, 2003, 3-11; Department of the Navy . MILSPERSMAN 1770, Casualties and 

 Survivor’s Benefi ts, Washington, D .C ., Feb . 13, 2008, 1-19; Department of the Air Force . AFI 36-3002, Casualty Service, Washington, D .C ., July 

 25, 2007, 31-66 .

111 Department of Defense . DoDD 1300 .22, Mortuary Aff airs Policy, Feb . 3, 2000, 2, 5; Department of the Army . AR 638-2, Care and Disposition 

 of Remains and Disposition of Personal Eff ects, Washington, D .C ., Dec . 22, 2000, 12-24; Department of the Air Force . AFI 34-242, Mortuary Aff airs 

 Program, Washington, D .C ., Apr . 2, 2008, 48-56; DoD Decedent Aff airs Manual . Decedent Aff airs Program, Washington, D .C ., Sept . 17, 1987, 2-1, 2-21 .

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48

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49

Our healthcare providers play an important role as force multipliers, keeping our fighting force physically 

and mentally fit. How we handle military mental health affects operational readiness. Our caregivers 

are not immune to the cumulative psychological effects of persistent conflict. They serve alongside 

our combat forces where they provide quality care that is second-to-none. They experience, share, and 

help our troops cope with the fears, grief, and concerns that accompany war against dangerous, tough, 

and elusive enemies. They often do not avail themselves of access to support resources similar to those 

that they provide to our fighting forces. Our review suggests that a culture exists in which military 

healthcare providers are encouraged to deny their own physical, psychological, and social needs to 

provide the necessary support to beneficiaries. Supporting and sustaining those who care for our forces 

translates to a healthy workplace, a culture of trust and respect, and caregivers who are invigorated rather 

than depleted by their intimate professional connections with traumatized patients.

The Department of Defense requires a comprehensive approach to 

ensure healthcare readiness—care for both warriors and caregivers. 

The Department of Defense should consider policies, procedures, 

and properly resourced programs to preserve our capabilities in this 

important combat service support area that include:

• leading the health provider force—by providing the 

senior mentoring and leadership necessary to groom 

tomorrow’s caregivers and establishing proper oversight to 

provide early warning of both patients and caregivers who may be dangers to themselves and others;

• maintaining the health provider force—by addressing health professionals’ readiness, ensuring 

we retain quality health providers, and developing deployment cycles that allow us to sustain the 

caregiver force just as we do for our combat and combat support forces;

• resourcing the health provider force—by increasing opportunities for the care and recovery of DoD 

healthcare providers.

For the purposes of this review, caregivers include healthcare providers and healthcare professionals as 

defined by the Department of Defense.

112 This group is further augmented with chaplains, medics, 

corpsmen, and counselors, whether deployed or in garrison.

Mental Health Care Support

Finding 5.1

• DoD installations are not consistent in adequately planning for mental health support for domestic 

mass casualty incidents to meet needs of victims and families.

• At Fort Hood, advanced treatment protocols developed at our universities and centers were not 

available to the commander prior to the incident.

• Fort Hood developed a Behavioral Health plan113 that incorporated current practices including a 

“whole of community” approach, and a strategy for long-term behavioral healthcare not reflected in 

any DoD policy.

112 Department of Defense. DoD Manual 6015.1-M, Glossary of Healthcare Terminology, January 1999, 75-76.

113 Campaign Plan PC 09-11-655, Fort Hood Behavioral Health Campaign Plan, Dec. 7, 2009, 1-2.

Chapter 5

Support to DoD Healthcare Providers

The Department of 

Defense requires a 

comprehensive approach 

to ensure health care 

readiness—care for both 

warriors and caregivers.
50

Discussion

Current Department of Defense medical policy regarding combat stress does not address traumatic stress 

response in a domestic mass casualty incident.

114 There are emerging advanced treatment techniques for 

traumatic stress that should inform DoD policies.

Several DoD programs and initiatives are working to optimize mental healthcare. The most advanced 

DoD programs or initiatives include the Uniformed Services University of Health Sciences’ Center for 

the Study of Traumatic Stress,115 the Department of Defense Task Force on Mental Health, and the 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

116

These programs have developed:

• A series of pamphlets entitled “Courage To Care,” to inform both patients and providers on a range 

of disaster mental health concerns.

117

• A standardized provider training curriculum for treating post traumatic stress disorder.

118

• Validated practice standards for treating psychological disorders to ensure the Department of 

Defense meets the needs of the nation’s military communities, warriors, and families.

119

• A series of preventive programs to mitigate development of psychological disorders in the aftermath 

of disasters.

Although the Department of Defense has not consistently incorporated these best practices into policy, 

a review of Service policies identified that current practices are reflected in an Air Force Instruction that 

provides a comprehensive, proactive approach to traumatic stress response.

120

Recommendation 5.1

• Update Mental Health Care clinical practice guidelines that address both combat and domestic 

incidents to ensure current and consistent preventive care.

• Review best practices inside and outside the Department of Defense to develop policies, programs, 

process, and procedures to provide commanders tools required to protect the force in the aftermath 

of combat or mass casualty incidents.

• Consider the Air Force Instruction and the Fort Hood Behavioral Health Campaign Plan as possible 

sources for developing appropriate guidance.

121

114 Department of Defense. DoDD 6490.5, Combat Stress Control Programs, Washington, D.C., Nov. 24, 2003, 1-9.

115 Uniformed Services University of the Health Services, Department of Psychiatry, http://www.usuhs.mil/psy/psychfellowships.html, (accessed Dec 10,

2009).

116 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, For Health Professionals, http://www.dcoe.health.mil/

ForHealthPros.aspx, (accessed Dec. 10, 2009).

117 Uniformed Services University of the Health Sciences. Courage to Care, Adherence: Addressing a Range of Patient Health Behaviors, Bethesda, MD; 

Uniformed Services University of the Health Sciences. Courage to Care, Staying the Course: Following Medical Recommendations for Health, Bethesda, MD.

118 Uniformed Services University of the Health Sciences. “USU Newsletter: Addressing the Psychological Health of Warriors,” Aug. 4, 2008, 3.

119 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, For Health Professionals, http://www.dcoe.health.mil/

forHealthPros.aspx, (accessed Dec. 8, 2009).

120 Department of the Air Force. AFI 44-153, Traumatic Stress Response, Washington, D.C., Mar. 31, 2006, 1-17.

121 Department of the Air Force. AFI 44-153, Traumatic Stress Response, Washington, D.C., Mar. 31, 2006, 1-17; Campaign Plan PC 09-11-665, Fort 

Hood Behavioral Health Campaign Plan, Dec 7, 2009, 1-17.
51

Finding 5.2

• Th e Department of Defense does not have comprehensive policies that recognize, defi ne, integrate, 

and synchronize monitoring and intervention eff orts to assess and build healthcare provider 

readiness .

• Th e Department of Defense does not have readiness sustainment models, with requisite resources, 

for the health provider force that are similar to readiness sustainment models for combat and combat 

support forces .

• Th e demand for support from caregivers in general, and from mental healthcare providers in 

particular, is increasing and appears likely to continue to increase due to the stress on military 

personnel and their families from our high operational tempo and repeated assignments in 

combat areas .

Discussion

Th e Services have a variety of policies, programs, and specifi c course content that present concepts on 

readiness and resilience as it applies to all Service members . Our review of Service policies, information 

papers, and individual interviews revealed that the emerging resiliency programs are currently described 

in various documents, but are not yet integrated across Service Doctrine .

Our review revealed that the Department of Defense 

currently does not endorse a program encompassing all 

of the desired attributes of a healthcare provider readiness 

strategy . As the Army and Navy continue to implement 

their programs, they are using a validated tool to assess 

eff ectiveness . Th is is a step in the right direction . Th ese 

Services recognize that addressing readiness levels may 

improve the retention of critically skilled personnel .122 

For those agencies using a monitoring tool, however, 

little actionable feedback is being provided to leaders to 

aff ect program development and sustainment . Th e use 

of a common tool would assist interagency and civilian 

intervention benchmarking, further extending program capability and eff ectiveness .

Th ere are evolving collaborations between DoD entities and civilian organizations to support healthcare 

providers . Our review suggests that it continues to be diffi cult for commanders at local levels to establish 

formal collaboration on readiness programs due to resource and contracting barriers . Research on the 

fi eld of secondary trauma suggests that preventive programs designed to provide comprehensive support 

to enhance resilience and reduce fatigue in behavioral health employees treating mental health problems 

(e .g ., Post Traumatic Stress Disorder) among service personnel are critical . Civilian programs that build 

on the already strong tradition of buddy systems in the military are particularly valuable .123

122 Interview with Coordinator of Mental Health Wellness Programs, Navy Bureau of Medicine and Surgery, Washington, D .C ., Dec 10, 2009 .

123 Dr . Charlie Benight, University of Colorado at Colorado Springs, National Center for Provider Resilience . SupportNet Program for Frontline 

 Providers for Traumatic Stress, Washington, D .C ., Dec . 7, 2009 .

Our review revealed 

that the Department of 

Defense currently does 

not endorse a program 

encompassing all of the 

desired attributes of 

a healthcare provider 

readiness strategy.

Chapter 5

Support to DoD Healthcare Providers
52

Recommendation 5.2

Create a body of policies that:

• recognizes, defines, and synchronizes efforts to support and measure healthcare provider readiness in 

garrison and deployed settings;

• addresses individual assessment, fatigue prevention, non-retribution, and reduced stigma for those 

seeking care, and appropriate procedures for supporting clinical practice during healthcare provider 

recovery;

• requires DoD and Uniformed Services University of Health Sciences curricula, training materials, 

and personnel performance management systems to incorporate healthcare provider self-care skills 

and readiness concepts;

• develop mechanisms for collaborating with civilian resiliency resources.

Finding 5.3

The lack of a readiness sustainment model for the health provider force, the unique stressors that 

healthcare providers experience, and the increasing demand for support combine to undermine force 

readiness—care for both warriors and healthcare providers.

Discussion

Healthcare providers experience the transmission of traumatic stress from one individual to another. 

The Department of Defense Task Force on Mental Health Report noted the importance of enhancing 

the resiliency and recovery of combatants due to the emotional pathologies of combat.

124 The Services 

have robust programs for pre- and post-deployment care for their members, but some have only recently 

initiated similar programs for healthcare providers.

125 It is equally important to enhance the resiliency 

and recovery of care providers.

126 These programs should be fully integrated, with lessons learned and 

best practices. The Services appear to have insufficient data to assess traumatic stress and healthcare 

provider burnout, critical elements in assessing stress control programs for the force. Programs for 

chaplains and others who support the religious ministry are notable for their comprehensive scope and 

effectiveness.

Despite the efforts of the Services, there is ongoing hesitancy among healthcare providers to seek 

treatment when they experience stress related to their roles as care providers. The professional ethic 

favors placing patient and organizational needs above personal health and emotional concerns.

Our healthcare readiness approach should balance the needs of patients with the needs of the providers. An 

example of a well-intentioned program that may have unintended consequences for our healthcare providers is 

the Army’s requirement for specific caregivers assigned to deployed Brigade Combat Teams to remain in their 

currently assigned Brigade Combat Teams for a minimum of 90 days after return from deployment. While 

providing continuity of care for returning soldiers, this may delay care provider recovery.

127

124 VADM Donald C. Arthur, USN, Shelley MacDermid, and LTG Kevin C. Kiley, USA. Washington, D.C., 2007.

125 Department of the Navy. Draft, 091104. Combat and Operational Stress Control, Washington, D.C., unpublished; LTC Steve Lewis, PhD, USA. 

Briefing to Chief of Staff of the Army. MEDCOM Provider Resiliency Training (PRT) Program, Dec 7, 2009.

126 Ibid.

127 ALARACT 214/2009, Stop Loss and Deployment Policy Updates, Aug. 4, 2009, 1-5.
53

Demand for healthcare support continues to increase . With high operational tempo and repeat tours 

in combat areas, the need for healthcare support will not level, much less diminish, in the foreseeable 

future . Th e superb care our military personnel and their families have received will be increasingly at 

risk if issues identifi ed in this report are not resolved quickly in an integrated, comprehensive manner .

Recommendation 5.3

• Develop integrated policies, processes, procedures, and properly resourced programs to sustain 

high quality care .

• Develop a deployment model that provides recovery and sustainment for healthcare providers 

comparable to that provided to the combat and combat support components of the force .

• Review the requirement for the Department of Defense to de-stigmatize healthcare providers who 

seek treatment for stress .

Finding 5.4

Senior caregivers are not consistently functioning as clinical peers and mentors to junior caregivers .

Discussion

Providing strong mentor relationships among healthcare providers and retaining experienced senior 

expertise at the clinical level are vital elements in providing quality healthcare . Current Service career 

patterns, with some recent innovative eff orts as important exceptions, move senior clinicians away 

from patient care to career-enhancing leadership positions . Th is leaves junior clinicians and support 

staff without the assistance of seasoned clinicians . Th is limited daily interaction with clinicallyand militarily-experienced mentors can hamper force development . Th e Army and the Navy have 

demonstrated a commitment to keep highly-trained academic physicians in the Medical Treatment 

Facilities for prolonged tours . Th e Air Force has developed an O-6 Senior Clinician Billet program 

to place senior physicians back in full-time clinical practice to serve as mentors and to share clinical 

expertise . Th ese experienced providers serve as reassuring role models and advisors to less experienced 

coworkers .128

Th e retention of experienced clinicians in the Services is a concern . While addressing the retention issue 

is beyond the scope of this inquiry, it should be noted that dissatisfaction with healthcare provider support 

can be identifi ed as a negative infl uence on career longevity . For example, data from the recent Air Force 

Medical Corps Exit Survey (while not fully representative or generalized) identifi es clinical, deployment, 

and administrative demands placed on physicians as common infl uences on decisions to separate from the 

Air Force Medical Service .129 As previously addressed, these demands may aff ect the Services’ abilities to 

integrate incentives to support provider readiness . Th e downward trajectory continues when providers are 

surrounded by teammates whose focus is on exiting the Service .

Recommendation 5.4

Review Senior Medical Corps Offi cer requirements to determine optimal roles, utilization, and 

assignments .

128 Col Arynce Pock, USAF, AF/SG1, “Position Description: O-6 Clinician,” Dec . 14, 2009 .

129 Col Arynce Pock, USAF, AF/SG 1M, email to Lt Col Janice Langen, USAF, Dec . 16, 2009 .

Chapter 5

Support to DoD Healthcare Providers
54

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A-1

Appendix A

Memorandum and Terms Of Reference
A-2
A-3

Appendix A

Memorandum and Terms of Reference
A-4

2
A-5

Appendix A

Memorandum and Terms Of Reference

3
A-6

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B-1

Executive Director

Col David Krumm, USAF

Director of Staff

Lt Col Donna Turner, USAF

Panel Staff

Mr. James Schwenk

CAPT Donald Gabrielson, USN

CDR John Rickards, USN

CDR Shawn Malone, USN

LTC James Clemonts, USA

Lt Col Rhonda Ozanian, USAF

Lt Col Charlie Underhill, USAF

LTC Heather Kness, USA

LtCol Matthew Phares, USMC

LTC Jonathan Withington, USA

MAJ Jonathan Due, USA

MAJ Bryan Price,PhD, USA

MSgt Tarri Long, USAF

Mr. Benjamin Bryant

Anthony C. Cain, PhD

Ms. Dorothy Hale

Ms. Desiree Parker

Ms. Liza Vivaldi

Mr. Thomas Zamberlan

Red Team

Ms. Sally Donnelly, Team Lead

CDR David Copp, USN

Mr. Howard Luker

Mr. James Mitchell

Frances Murphy, MD, MPH

Personnel Policies and Procedures

Gen Stephen Lorenz, USAF, Team Lead

COL (P) Billy D. Farris, USA, Deputy

Mr. James Neighbors, SES, Chief of Staff

BG Peter Zwack, USA

Col Dave Wesley, USAF

COL David Lemauk, USA

Chap (Col) Jerry Pitts, USAF

Lt Col Susanne Wheeler, USAF

LTC Teresa Gaborik, USA

LTC Brian Mack, USA

Maj David O’Malley, USAF

Maj Joshua Morganstein, USAF

Chap (LCDR) Charles Varsogea, USN

Capt Marrisa Carlton, USAF

SgtMaj William Skiles, USMC

MSG Stuart Coupe, USA

PSC Melanie Kinchen, USN

Mr. Marc A. Blincoe

Ms. Lynn Borkon

Mr. Fred Bryant

Ms. Victoria Darwin

Maren Leed, PhD

Ms. Melissa Lopez

Laura Miller, PhD

Mr. Dorian Sajona

Ms. Marcella Sandiford

Mr. George Truss

Force Protection

RADM Mark Buzby, USN, Team Lead

Mr. Raymond Geoffroy, SES, Deputy 

CAPT Chris Kiley, USN, Chief of Staff 

Lt Col Eric Knapp, USAF

Ms. Lisa Burgess

Mr. James Cain

Mr. Michael Dickey

Mr. Kevin Dodds

Ms. Rhonda Gayle

Mr. Kevin Naylon

Mr. Eugene Smith

Mr. John Gregory Steele

Mr. Thaldaris Talley

Mr. John Vesterman

Emergency Management & Response

LtGen Frank Panter, USMC, Team Lead

Brig Gen Jeffery Lofgren, USAF, Deputy

Capt Jay Montgomery, USMC, Chief of Staff

CH (COL) Clark McGriff, USA

COL Knickerbocker, USA

COL Kathleen Ford, USA

CDR Sawsan Ghurani, USN

CDR Eric Runnels, USCG

Appendix B

Panel Roster
B-2

Charles Beadling, MD

Ms. Cheryl Hackley

Mr. Owen McIntyre

Mr. Todd Rose

Mr. Thomas Ruffini

Mr. Randy Smith

Mr. Mark Ward

Ms. Gabriela Wilson

Application of Policies and Procedures

GEN Carter Ham, USA, Team Lead

MG Bill McCoy, USA, Deputy

Mr. James Neighbors, SES, Chief of Staff

Maj Gen Thomas Travis, USAF

Brig Gen Eden Murrie, USAF

Col James Black, USAF

COL Cornelius Maher, USA

COL Doreen Lounsbery, USA

Col Christopher O’Brien, USAF

Col Gerald Talcott, USAF

Lt Col Bill Fischer, USAF

LTC Christopher Carrier, USA

Maj Dan Janning, USAF

Maj Elizabeth Greene, USAF

MAJ Wesley Howard, USA

Capt Sarah Carpenter, USAF

Ms. Sonja Ackar

Mr. Bruce Barry

Ms. Ellen Campana

Mr. Edgar Collins

Mr. Hal Dronberger

Mr. James Fazio

Ms. Georganna Murto

Mr. Hung Nguyen

Ms. Amanda Smith

Ms. Debra Tolson

Mr. Carl Witcher

Care for Healthcare Providers

RADM Karen Flaherty, USN, Team Lead

CH (COL) John Read, USA, Deputy

CDR Anne Swap, USN, Chief of Staff

COL Kelly Wolgast, USA

Lt Col Janice M. Langer, MD, USAF

CDR Rosemary Carr Malone, MD, USN

CDR Barry Adams, PhD, LCSW, USN

Lt Col Teresa Roberts, LCSW, USAF

MAJ Todd Yosick, USA

LCDR James Cannon, PhD, PA, USCG

SGM Devon Matthew, USA

SMSgt Glynda Lilly, USAF

Mr. Dale Hamby

Ms. Mary Woodward
C-1

Finding 2.1

DoD programs, policies, processes, and procedures that address identification of indicators for violence 

are outdated, incomplete, and fail to include key indicators of potentially violent behaviors.

Recommendation 2.1

• Update training and education programs to help DoD personnel identify contributing factors and 

behavioral indicators of potentially violent actors.

• Coordinate with the FBI Behavioral Science Unit’s Military Violence unit to identify behavioral 

indicators that are specific to DoD personnel.

• Develop a risk assessment tool for commanders, supervisors, and professional support service 

providers to determine whether and when DoD personnel present risks for various types of violent 

behavior.

• Develop programs to educate DoD personnel about indicators that signal when individuals may 

commit violent acts or become radicalized.

Finding 2.2

Background checks on personnel entering the DoD workforce or gaining access to installations may be 

incomplete, too limited in scope, or not conducted at all.

Recommendation 2.2

• Evaluate background check policies and issue appropriate updates.

• Review the appropriateness of the depth and scope of the National Agency Check with Local Agency 

and Credit Check as minimum background investigation for DoD SECRET clearance.

• Educate commanders, supervisors, and legal advisors on how to detect and act on potentially adverse 

behaviors that could pose internal threats.

• Review current expedited processes for citizenship and clearances to ensure risk is sufficiently 

mitigated.

Finding 2.3

DoD standards for denying requests for recognition as an ecclesiastical endorser of chaplains may be 

inadequate.

Recommendation 2.3

Review the limitations on denying requests for recognition as ecclesiastical endorsers of chaplains.

Finding 2.4

The Department of Defense has limited ability to investigate Foreign National DoD military and 

civilian personnel who require access to DoD information systems and facilities in the U.S. and abroad.

Appendix C

Summary of Findings and Recommendations
C-2

Recommendation 2.4

Coordinate with the Department of State and Office of Personnel Management to establish and 

implement more rigorous standards and procedures for investigating Foreign National DoD personnel.

Finding 2.5

The policies and procedures governing assessment for pre- and post-deployment medical risks do not 

provide a comprehensive assessment of violence indicators.

Recommendation 2.5

• Assess whether pre- and post-deployment behavioral screening should include a comprehensive 

violence risk assessment.

• Review the need for additional post-deployment screening to assess long-term behavioral indicators 

that may point to progressive indicators of violence.

• Revise pre- and post-deployment behavioral screening to include behavioral indicators that a person 

may commit violent acts or become radicalized.

• Review policies governing sharing healthcare assessments with commanders and supervisors to allow 

information regarding individuals who may commit violent acts to become available to appropriate 

authorities.

Finding 2.6

The Services have programs and policies to address prevention and intervention for suicide, sexual 

assault, and family violence, but guidance concerning workplace violence and the potential for selfradicalization is insufficient.

Recommendation 2.6

• Revise current policies and procedures to address preventing violence toward others in the workplace.

• Integrate existing programs such as suicide, sexual assault, and family violence prevention with 

information on violence and self-radicalization to provide a comprehensive prevention and response 

program.

Finding 2.7

DoD policy regarding religious accommodation lacks the clarity necessary to help commanders 

distinguish appropriate religious practices from those that might indicate a potential for violence or selfradicalization.

Recommendation 2.7

Promptly establish standards and reporting procedures that clarify guidelines for religious 

accommodation.
C-3

Finding 2.8

DoD Instruction 5240 .6, Counterintelligence (CI) Awareness, Briefi ng, and Reporting Programs, does 

not thoroughly address emerging threats, including self-radicalization, which may contribute to an 

individual’s potential to commit violence .

Recommendation 2.8

Update DoD Instruction 5240 .6 to provide specifi c guidance to the Services, Combatant Commands, 

and appropriate agencies for counterintelligence awareness of the full spectrum of threat information 

particularly as it applies to behavioral indicators that could identify self-radicalization .

Finding 2.9

DoD and Service guidance does not provide for maintaining and transferring all relevant information 

about contributing factors and behavioral indicators throughout Service members’ careers .

Recommendation 2.9

• Review what additional information (e .g ., information about accession waivers, substance abuse, 

minor law enforcement infractions, conduct waivers) should be maintained throughout Service 

members’ careers as they change duty locations, deploy, and re-enlist .

• Develop supporting policies and procedures for commanders and supervisors to access this 

information .

Finding 2.10

Th ere is no consolidated criminal investigation database available to all DoD law enforcement and 

criminal investigation organizations .

Recommendation 2.10

Establish a consolidated criminal investigation and law enforcement database such as the Defense Law 

Enforcement Exchange .

Finding 2.11

DoD guidance on establishing information sharing agreements with Federal, State, and local law 

enforcement and criminal investigation organizations does not mandate action or provide clear 

standards .

Recommendation 2.11

Require the Military Departments and Defense Agencies to establish formal information sharing 

agreements with allied and partner agencies; Federal, State, and local law enforcement; and criminal 

investigation agencies, with clearly established standards regarding scope and timeliness .

Appendix C

Summary of Findings and Recommendations
C-4

Finding 2.12

Policies governing communicating protected health information to other persons or agencies are 

adequate at the DoD-level, though they currently exist only as interim guidance. The Services, however, 

have not updated their policies to reflect this guidance.

Recommendation 2.12

Ensure Services update policies to reflect current DoD-level guidance on the release of protected health 

information.

Finding 2.13

Commanders and military healthcare providers do not have visibility on risk indicators of Service 

members who seek care from civilian medical entities.

Recommendation 2.13

Consider seeking adoption of policies and procedures to ensure thorough and timely dissemination of 

relevant Service member violence risk indicators from civilian entities to command and military medical 

personnel.

Finding 2.14

The Department of Defense does not have a comprehensive and coordinated policy for 

counterintelligence activities in cyberspace. There are numerous DoD and interagency organizations and 

offices involved in defense cyber activities.

Recommendation 2.14

Publish policy to ensure timely counterintelligence collection, investigations, and operations in 

cyberspace for identifying potential threats to DoD personnel, information, and facilities.

Finding 2.15

DoD policy governing prohibited activities is unclear and does not provide commanders and supervisors 

the guidance and authority to act on potential threats to good order and discipline.

Recommendation 2.15

Review prohibited activities and recommend necessary policy changes.

Finding 2.16

Authorities governing civilian personnel are insufficient to support commanders and supervisors as they 

attempt to identify indicators of violence or take actions to prevent violence.
C-5

Recommendation 2.16

Review civilian personnel policies to determine whether additional authorities or policies would enhance 

visibility on indicators of possible violence and provide greater fl exibility to address behaviors of concern .

Finding 3.1

• Th e Department of Defense has not issued an integrating force protection policy .

• Senior DoD offi cials have issued DoD policy in several force protection-related subject areas such as 

antiterrorism but these policies are not well integrated .

Recommendation 3.1

• Assign a senior DoD offi cial responsibility for integrating force protection policy throughout the 

Department .

• Clarify geographic combatant commander and military department responsibilities for force protection .

• Review force protection command and control relationships to ensure they are clear .

Finding 3.2

DoD force protection programs and policies are not focused on internal threats .

Recommendation 3.2

• Develop policy and procedures to integrate the currently disparate eff orts to defend DoD resources 

and people against internal threats .

• Commission a multidisciplinary group to examine and evaluate existing threat assessment programs; 

examine other branches of government for successful programs and best practices to establish 

standards, training, reporting requirements /mechanisms, and procedures for assessing predictive 

indicators relating to pending violence .

• Provide commanders with a multidisciplinary capability, based on best practices such as the Navy’s 

Th reat Management Unit, the Postal Service’s “Going Postal Program,” and Stanford University’s 

workplace violence program, focused on predicting and preventing insider attacks .

Finding 3.3

Th e Department of Defense’s commitment to support JTTFs is inadequate .

Recommendation 3.3

• Identify a single point of contact for functional management of the Department of Defense’s 

commitment to the JTTF program .

• Evaluate and revise, as appropriate, the governing memoranda of understanding between the FBI 

and diff erent DoD entities involved with the JTTF to ensure consistent outcomes .

• Review the commitment of resources to the JTTFs and align the commitment based on priorities 

and requirements .

Appendix C

Summary of Findings and Recommendations
C-6

Finding 3.4

There is no formal guidance standardizing how to share Force Protection threat information across the 

Services or the Combatant Commands.

Recommendation 3.4

Direct the development of standard guidance regarding how military criminal investigative organizations 

and counterintelligence organizations will inform the operational chain of command.

Finding 3.5

The Department of Defense does not have direct access to a force protection threat reporting system for 

suspicious incident activity reports.

Recommendation 3.5

• Adopt a common force protection threat reporting system for documenting, storing, and exchanging 

threat information related to DoD personnel, facilities, and forces in transit.

• Appoint a single Executive Agent to implement, manage, and oversee this force protection threat 

reporting system.

Finding 3.6

There are no force protection processes or procedures to share real-time event information among 

commands, installations, and components.

Recommendation 3.6

Evaluate the requirement for creating systems, processes, policy, and tools to share near real-time, 

unclassified force protection information among military installations in CONUS to increase situational 

awareness and security response.

Finding 3.7

DoD installation access control systems and processes do not incorporate behavioral screening strategies 

and capabilities, and are not configured to detect an insider threat.

Recommendation 3.7

• Review best practices, including programs outside the U.S. Government, to determine whether 

elements of those programs could be adopted to augment access control protocols to detect persons 

who pose a threat.

• Review leading edge tools and technologies that augment physical inspection for protecting the force.
C-7

Finding 3.8

Th e Department of Defense does not have a policy governing privately owned weapons . 

Recommendation 3.8

Review the need for DoD privately owned weapons policy .

Finding 3.9

Services cannot share information on personnel and vehicles registered on installations, installation 

debarment lists, and other relevant information required to screen personnel and vehicles, and grant 

access .

Recommendation 3.9

• Develop timely information sharing capabilities among components including vehicle registration, 

installation debarment lists, and other access control information .

• Accelerate eff orts to automate access control that will authenticate various identifi cation media (e .g ., 

passports, CAC, drivers’ licenses, license plates) against authoritative databases .

• Obtain suffi cient access to appropriate threat databases and disseminate information to local 

commanders to enable screening at CONUS and overseas installation access control points .

Finding 4.1

Services are not fully interoperable with all military and civilian emergency management stakeholders .

Recommendation 4.1

• Establish milestones for reaching full compliance with the Installation Emergency Management 

program .

• Assess the potential for accelerating the timeline for compliance with the Installation Emergency 

Management program .

Finding 4.2

Th ere is no DoD policy implementing public law for a 911 capability on DoD installations . Failure 

to implement policy will deny the military community the same level of emergency response as those 

communities off base .

Recommendation 4.2

Develop policy that provides implementation guidance for Enhanced 911 services in accordance with 

applicable laws .

Appendix C

Summary of Findings and Recommendations
C-8

Finding 4.3

DoD policy does not currently take advantage of successful models for active shooter response for 

civilian and military law enforcement on DoD installations and facilities.

Recommendation 4.3

• Identify and incorporate civilian law enforcement best practices, to include response to the active 

shooter threat, into training certifications for civilian police and security guards.

• Include military law enforcement in the development of minimum training standards to ensure 

standard law enforcement practices throughout the Department of Defense.

• Incorporate the Department of Homeland Security best practices regarding workplace violence and 

active shooter awareness training into existing personal security awareness training contained in 

current Level 1 Antiterrorism Awareness training.

• Develop a case study based on the Fort Hood incident to be used in installation commander 

development and on-scene commander response programs.

Finding 4.4

Based on Joint Staff Integrated Vulnerability Assessments, many DoD installations lack mass notification 

capabilities.

Recommendation 4.4

Examine the feasibility of advancing the procurement and deployment of state-of-the-art mass warning 

systems and incorporate these technologies into emergency response plans.

Finding 4.5

Services have not widely deployed or integrated a Common Operational Picture capability into 

Installation Emergency Operations Centers per DoD direction.

Recommendation 4.5

• Examine the feasibility of accelerating the deployment of a state-of-the-art Common Operational 

Picture to support installation Emergency Operations Centers.

• Develop an operational approach that raises the Force Protection Condition in response to a 

scenario appropriately and returns to normal while considering both the nature of the threat and the 

implications for force recovery and healthcare readiness in the aftermath of the incident.

Finding 4.6

• Stakeholders in the DoD Installation Emergency Management program, including the Under 

Secretary of Defense for Policy; Under Secretary for Personnel and Readiness; Under Secretary 

of Defense for Intelligence; Under Secretary of Defense for Acquisition, Technology & Logistics; 

Assistant Secretary of Defense for Public Affairs; and Assistant Secretary of Defense for Networks 
C-9

and Information Integration/Chief Information Offi cer, have not yet synchronized their applicable 

programs, policies, processes, and procedures .

• Better synchronization and coordination would remove redundant planning requirements, identify 

seams in policy, focus programmed resources, and streamline procedures to achieve unity of eff ort in 

installation emergency management .

Recommendation 4.6

• Review responsibilities for synchronizing Offi ce of the Secretary Defense programs, policies, and 

procedures related to installation emergency management .

• Establish policy requiring internal synchronizing of installation programs, plans, and response for 

emergency management .

Finding 4.7

Mutual Aid Agreements (MAAs) between DoD and civilian support agencies across the Services are not 

current .

Recommendation 4.7

Review Installation Emergency Management programs to ensure correct guidance on integrating 

tracking, exercising, and inspections of MAAs .

Finding 4.8

Th e Department of Defense has not produced guidance to develop family assistance plans for mass 

casualty and crisis response . As a result, Service-level planning lacks consistency and specifi city, which 

leads to variation in the delivery of victim and family care .

Recommendation 4.8

• Develop guidance incorporating the core service elements of a Family Assistance Center as identifi ed 

in the Pentagon AAR .

• Develop implementation guidance to establish requirements for a Family Assistance Center crisis and 

mass casualty response as integral components of Installation Emergency Management plans .

• Consider the Air Force’s Emergency Family Assistance Control Center and the Fort Hood 

Behavioral Health Campaign Plan as possible best practices when developing policy .

Finding 4.9

Th e lack of published guidance for religious support in mass casualty incidents hampers integration of 

religious support to installation emergency management plans .

Recommendation 4.9

• Consider modifying DoD and Service programs designed to promote, maintain, or restore health 

and well-being to off er each person the services of a chaplain or religious ministry professional .

• Develop policy for religious support in response to mass casualty incidents and integrate guidance 

with the Installation Emergency Management Program .

Appendix C

Summary of Findings and Recommendations
C-10

Finding 4.10

Inconsistencies among Service entry level chaplain training programs can result in inadequate 

preparation of new chaplains to provide religious support during a mass casualty incident.

Recommendation 4.10

Review mass casualty incident response training in the Chaplain Basic Officer Courses.

Finding 4.11

The Department of Defense has not yet published guidance regarding installation or unit memorial 

service entitlements based on the new Congressional authorization to ensure uniform application 

throughout the Department.

Recommendation 4.11

Develop standardized policy guidance on memorial service entitlements.

Finding 4.12

• DoD casualty affairs policy, Federal law, and DoD mortuary affairs guidance do not exist regarding 

injury or death of a private citizen with no DoD affiliation on a military installation within 

CONUS.

• There is no prescribed process to identify lead agencies for casualty notification and assistance or to 

provide care for the deceased, resulting in each case being handled in an ad-hoc manner.

Recommendation 4.12

• Review current policies regarding casualty reporting and assistance to the survivors of a private 

citizen with no DoD affiliation, who is injured or dies on a military installation within CONUS.

• Review current mortuary affairs policies relating to mortuary services for private citizens who 

become fatalities on a military installation within CONUS.

Finding 5.1

• DoD installations are not consistent in adequately planning for mental health support for domestic 

mass casualty incidents to meet needs of victims and families.

• At Fort Hood, advanced treatment protocols developed at our universities and centers were not 

available to the commander prior to the incident.

• Fort Hood developed a Behavioral Health plan that incorporated current practices including a 

“whole of community” approach, and a strategy for long-term behavioral healthcare not reflected in 

any DoD policy.
C-11

Recommendation 5.1

• Update Mental Health Care clinical practice guidelines that address both combat and domestic 

incidents to ensure current and consistent preventive care .

• Review best practices inside and outside the Department of Defense to develop policies, programs, 

processes, and procedures to provide commanders tools required to protect the force in the aftermath 

of combat or mass casualty incidents .

• Consider the Air Force Instruction and the Fort Hood Behavioral Health Campaign Plan as possible 

sources for developing appropriate guidance .

Finding 5.2

• Th e Department of Defense does not have comprehensive policies that recognize, defi ne, integrate, 

and synchronize monitoring and intervention eff orts to assess and build healthcare provider 

readiness .

• Th e Department of Defense does not have readiness sustainment models, with requisite resources, 

for the health provider force that are similar to readiness sustainment models for combat and combat 

support forces .

• Th e demand for support from caregivers in general, and from mental healthcare providers in 

particular, is increasing and appears likely to continue to increase due to the stress on military 

personnel and their families from our high operational tempo and repeated assignments in 

combat areas .

Recommendation 5.2

Create a body of policies that:

• recognizes, defi nes, and synchronizes eff orts to support and measure healthcare provider readiness in 

garrison and deployed settings;

• addresses individual assessment, fatigue prevention, non-retribution, and reduced stigma for those 

seeking care, and appropriate procedures for supporting clinical practice during healthcare provider 

recovery;

• requires DoD and Uniformed Services University of Health Sciences curricula, training materials, 

and personnel performance management systems to incorporate healthcare provider self-care skills 

and readiness concepts; 

• develop mechanisms for collaborating with civilian resiliency resources .

Finding 5.3

Th e lack of a readiness sustainment model for the health provider force, the unique stressors that 

healthcare providers experience, and the increasing demand for support combine to undermine force 

readiness—care for both warriors and healthcare providers .

Recommendation 5.3

• Develop integrated policies, processes, procedures, and properly resourced programs to sustain 

high quality care .

Appendix C

Summary of Findings and Recommendations
C-12

• Develop a deployment model that provides recovery and sustainment for healthcare providers 

comparable to that provided to the combat and combat support components of the force.

• Review the requirement for the Department of Defense to de-stigmatize healthcare providers who 

seek treatment for stress.

Finding 5.4

Senior caregivers are not consistently functioning as clinical peers and mentors to junior caregivers.

Recommendation 5.4

Review Senior Medical Corps Officer requirements to determine optimal roles, utilization, and 

assignments.
D-1

This Appendix highlights some major themes in the academic literature, based primarily on literature 

reviews from 2000 – the present. Within categories of violence (e.g., suicide, terrorism, sexual violence), 

researchers have sought ways to distinguish those who carry out acts of violence from those who do not. 

Researchers also have studied particular risk factors (e.g., substance abuse, mental illness) to determine 

which types of violence are associated with specific risk factors and why.

1

 Overarching themes on risk 

factors for violence toward self or others include the following:

Predicting Violent Behavior 

is a Long-Term Multi-Disciplinary Quest

Researchers have yet to develop a single model that can estimate who is at risk for any type of violence, 

but they have made progress on models to identify risks for particular forms of violence, or specific 

populations, such as psychiatric patients.

2

Most research to date has been conducted on physical violence perpetrated by individuals.

3

 No field has 

substantiated the image of violence emerging from a normal, happy, healthy individual who suddenly 

“snaps” in the face of a single triggering event. In addition, no single variable has been identified that 

can accurately predict violence.

Identifying potentially dangerous people before they act is difficult. Examinations after the fact show 

that people who commit violence usually have one or more risk factors for violence. Few people in the 

population who have risk factors, however, actually assault or kill themselves or others. For example, 

many people experience depression, but relatively few attempt or die by suicide. Most people who 

commit violence are male, but most males do not commit violence. Exposure to childhood violence may 

increase the likelihood that someone may harm themselves or others, but it is not inevitable. Certain 

combinations of risk factors, however, can significantly increase the likelihood that individuals will 

become violent.

Risk Factors Vary Across Types of Violence

The range of contributing factors for different types of violence is diverse. Although some factors, such 

as low self-esteem, depression, and anger are tied to many different types of violence, others are more 

particular to specific types of aggression. DoD policies and programs that focus on the risk factors for 

only a few types of violence miss indicators of other types of violence that threaten its community.

1 Trevor Bennett, Katy Holloway, and David Farrington, “The Statistical Association Between Drug Misuse and Crime: A Meta-Analysis,” Aggression 

and Violent Behavior 13 (2008): 107-118; Eric B. Elbogen and Sally C. Johnson, “The Intricate Link Between Violence and Mental Disorder: Results 

From the National Epidemiologic Survey on Alcohol and Related Conditions,” Archives of General Psychiatry 66:2 (2009): 152-161; Seena Fazel, Johanna 

Philipson, Lisa Gardiner, Rowena Merritt, and Martin Grann, “Neurological Disorders and Violence: A Systematic Review and Meta-Analysis with a 

Focus on Epilepsy and Traumatic Brain Injury,” Journal of Neurology 256 (2009): 1591-1602; Christopher J. Ferguson and Kevin M. Beaver, “Natural 

Born Killers: The Genetic Origins of Extreme Violence,” Aggression and Violent Behavior 14:5 (2009):286-294; Andrew Harris, and Arthur J. Lurigio, 

“Mental Illness and Violence: A Brief Review of Research and Assessment Strategies,” Aggression and Violent Behavior 12 (2007): 542-551; Robert 

MacCoun, Beau Kilmer, and Peter Reuter, “Research on Drugs-Crime Linkages: The Next Generation,” Toward a Drugs and Crime Research Agenda for 

the 21st Century: U.S. Department of Justice, National Institute of Justice (2003).

2 Mary Ann Campbell, Sheila French, and Paul Gendreau, “The Prediction of Violence in Adult Offenders: A Meta-Analytic Comparison of Instruments 

and Methods of Assessment,” Criminal Justice and Behavior 35:6 (2009): 567-590; Mark E. Olver, Keira C. Stockdale, and J. Stephen Wormith, “Risk 

Assessment With Young Offenders: A Meta-Analysis of Three Assessment Measures,” Criminal Justice and Behavior 36:4 (2009): 329-353; E. Fuller 

Torrey, John Monahan, Jonathan Stanley, Henry J. Steadman, and the MacArthur Study Group, “The MacArthur Violence Risk Assessment Study 

Revisited: Two Views Ten Years After Its Initial Publication,” Psychiatric Services 59:2 (2008): 147-152.

3 Mary R. Jackman, “Violence in Social Life,” Annual Review of Sociology 28 (2002): 387-415.

Appendix D

Literature Review of Risk Factors for Violence
D-2

The following overview of risk factors illustrates why DoD personnel need more than a simple checklist 

to determine whether someone may become violent:

Each year, more than one million people in the U.S. are harmed by workplace violence, and an estimated 

17,000 take their own lives in their place of employment.

4

 The portrait of the “disgruntled” employee 

who “goes postal” and kills a supervisor does not encompass the full array of workplace homicides: 

customers, clients, peers, and superiors are also responsible. The rates of workplace violence in the U.S.

Postal Service are actually lower than in the general workforce, so that organization, despite the popular 

phrase, does not provide a “worst case” for study.

Attempts to use personality tests to screen out potentially violent employees at entry have been unreliable. In 

addition, research has not yet established a link between mental illness and workplace violence.

5

 Other behavioral 

indicators have been identified, however. For example, those who commit workplace violence often believe 

they have been wronged, such as having been denied service or subjected to a poorly handled lay-off or firing.

6

Although domestic terrorism is far more common than international terrorism, research on terrorism 

focuses on the latter.

7

 Motivations for domestic terrorism are diverse, and include animal rights, 

environmentalism, nationalism, white supremacy, religious causes, and right-wing politics.

8

 Overall, acts 

of domestic terrorism tend to occur in large urban areas and target the police and military forces.

9

Recent research has focused on why individuals become terrorists.

10 Although some people self-radicalize as 

individuals, more commonly small groups of people self-radicalize together.

11 Group dynamics can foster the 

dehumanization of targets and the drive to commit violence.

12 In addition, the path to terrorism often involves 

some real or perceived rewards for participation, the desire to address grievances, and a passion for change.

13

As with workplace violence, mental illness has not been identified as a contributing factor in the path to 

terrorism.

14 Furthermore, terrorists are not particularly poor or uneducated.15

4 Gregory M. Vecchi, “Conflict & Crisis Communication: Workplace and School Violence, Stockholm Syndrome, and Abnormal Psychology,” Annals of 

the American Psychotherapy Association 12:3 (2009): 30-39.

5 Julian Barling, Kathryne E. Dupré, and E. Kevin Kelloway, “Predicting Workplace Aggression and Violence,” Annual Review of Psychology 60 (2009): 

671-692.

6 Barling, Dupré and Kelloway, 671-692.

7 Ignacio Sánchez-Cuenca and Luis de la Calle, “Domestic Terrorism: The Hidden Side of Political Violence,” Annual Review of Political Science 12 

(2009): 31-49.

8 Samuel Nunn, “Incidents of Terrorism in the United States, 1997-2005,” Geographical Review 97:1 (2007): 89-111.

9 Samuel Nunn, “Incidents of Terrorism in the United States, 1997-2005,” Geographical Review 97:1 (2007): 89-111; Ignacio Sánchez-Cuenca and Luis 

de la Calle, “Domestic Terrorism: The Hidden Side of Political Violence,” Annual Review of Political Science 12 (2009): 31-49; Brent Smith, “A Look at 

Terrorist Behavior: How They Prepare, Where They Strike,” NIJ Journal 260 (2008): 2-6.

10 Paul K. Davis and Kim Cragin, eds. Social Science for Counterterrorism (Santa Monica: RAND, 2009); Austin T. Turk, “Sociology of Terrorism,” Annual 

Review of Sociology 30 (2004): 271-286.

11 Todd C. Helmus, “Why and How Some People Become Terrorists,” in Davis and Cragin, eds: Social Science for Counterterrorism (Santa Monica: RAND, 

2009), 71-111.

12 Ibid.

13 Ibid.

14 Ibid.

15 Ibid. 
D-3

Religious fundamentalism alone is not a risk factor; most fundamentalist groups are not violent, and 

religious-based violence is not confi ned to members of fundamentalist groups .16

Violence against family members is more common than violence against strangers . Although the factors leading to 

domestic violence, child abuse, and elder abuse are not identical, key factors in common include: prior aggression, 

being a victim of or witnessing violence in childhood, low impulse control, low self esteem, poor relationship and 

communication skills, substance abuse, low income, stress, mental health problems, and antisocial behaviors/

antisocial personality disorder .17 Th e risk for intimate partner homicides is higher in homes with domestic violence, 

fi rearms, and illicit drug use .18 Most murder-suicides involve a middle-aged or older man (nearly 100 percent 

male) using a fi rearm to kill his current or former wife or girlfriend and then himself, often after the couple has 

recently separated or there is a pending estrangement .19 Rates of depression are higher in these cases than in 

cases of homicide alone, but rates of substance abuse or previous criminal behavior were lower .20

Studies of suicide highlight the risk factors of particular mental illnesses, substance abuse, previous 

suicide attempts, exposure to suicide, social isolation, major physical illnesses, poor impulse control, 

history of aggression, trauma, or abuse .21 Some events such as divorce, loss of a job, or death of a loved 

one, may trigger suicide in those who are already vulnerable .

People who commit sexual violence are diverse, but researchers and law enforcement organizations have 

created typologies for various forms of sexual violence .22 Th ese typologies assist with the recognition, 

investigation, and treatment of sexual off enders . Although there is variation in motivation and methods, 

rapists tend to share some characteristics, such as negative views of women, hyper-identifi cation with the 

masculine role, low self esteem, substance abuse problems, and problems managing aggression .23 Common 

characteristics of child molesters are poor social skills, low self-esteem, problems forming adult relationships, 

and a pattern of “grooming” children with manipulative behavior so they will be compliant .24

Cyber off enders represent a new category of assailant, following the rise of the Internet and its use by 

sexual predators to identify and groom children . Female sex off enders have received less attention, and 

have been treated as their own category due to the diff erence in characteristics: women are less likely to 

use force, begin off ending at an earlier age (although are less likely to have begun in childhood), and are 

16 Michael O . Emerson, and David Hartman, “Th e Rise of Religious Fundamentalism,” Annual Review of Sociology 32 (2006): 127-144 .

17 Patrick Tolan, Deborah Gorman-Smith, and David Henry, “Family Violence,” Annual Review of Psychology 57 (2006): 557-583 .

18 Lorena Garcia, Catalina Soria and Eric L . Hurwitz, “Homicides and Intimate Partner Violence: A Literature Review,” Trauma, Violence & Abuse 8: 4 

(2007): 370-383 .

19 Scott Eliason, “Murder-Suicide: A Review of the Recent Literature,” Th e Journal of the American Academy of Psychiatry and Law 37:3 (2009): 371-376; 

Marieke Liem, “Homicide Followed By Suicide: A Review,” Aggression and Violent Behavior (2009), doi:10 .1016/j .avb .2009 .10 .001 .

20 Eliason, 371-376 .

21 Risk and Protective Factors for Suicide, Suicide Prevention Resource Center (SAMHSA) 2009, http://www .sprc .org/suicide_prev_basics/index .asp . 

[Original source: the National Strategy for Suicide Prevention: Goals and Objectives for Action (2001) .

22 (Oliver) Heng-Choon Chan, and Kathleen M . Heide, “Sexual Homicide: A Synthesis of the Literature,” Trauma, Violence & Abuse 10:1 (2009): 31-54 .

23 Gina Robertiello and Karen J . Terry, “Can We Profi le Sex Off enders? A Review of Sex Off ender Typologies,” Aggression and Violent Behavior 12 (2007): 

508-518 .

24 Ibid .

Appendix D

Literature Review of Risk Factors for Violence
D-4

likely to be influenced by male offenders to abuse.

25 Various typologies have been proposed for juvenile 

sex offenders but no standard classification appears to have been adopted yet.

U.S. homicide rates exceed those of any comparable nations.

26 Violence and criminal behavior peaks 

in adolescence and young adulthood, and is preceded by risk factors such as aggression; exposure to 

violence; poor parenting; academic failure; negative peer influences; living in neighborhoods with a high 

concentration of poor residents; limited economic opportunities; access to firearms, alcohol and illicit 

drug use; high levels of transiency; and family disruption.

27 Research on homicide is better developed 

than research on multiple homicides, such as serial killing, spree killing, and mass murder.

28

Application for the Department of Defense

Current knowledge from research could strengthen the Department of Defense’s violence prevention 

efforts and assist with implementation of the recommendations offered in the Personnel Policies chapter 

of this repport. Known risk factors could be incorporated into the criteria for entry-level background 

checks and for citizenship and security clearances.

The integration of current knowledge into professional military education could provide supervisors and 

commanders the tools they need to make judgment calls in disciplinary cases, and when conducting 

performance and career counseling. This knowledge could also influence the types of adverse 

information that is recorded and shared throughout Service members’ careers.

Research on workplace violence should guide improvements to mitigation efforts. Cutting-edge research 

on the pathways to terrorism should be used to update counterintelligence programs. Research on how 

cyberspace can foster violence should inform policy revisions for prohibited activities and cyber-related 

threats.

Dr. Greg Vecchi, who leads the FBI’s Behavioral Science Unit, explained other ways that current 

information about offenders can be useful. For example, greater understanding of offender motivations 

and means can improve interactions with them, particularly when they make a direct threat.

29 This 

knowledge can also assist in the investigation of violent crimes or suspicious personnel. For example, a 

search of personal belongings might reveal items typical for certain types of offenders, such as literature 

advocating violence, personal manifestos, and souvenirs or documentation of crimes.

Academics have been developing violence risk assessment tools that the Department of Defense could 

employ or emulate. For example, the MacArthur Violence Risk Assessment Study produced a model to 

predict risk of violence among patients recently discharged from psychiatric facilities. Software 

25 Gina Robertiello and Karen J. Terry, “Can We Profile Sex Offenders? A Review of Sex Offender Typologies,” Aggression and Violent Behavior 12 (2007): 

508-518.

26 Linda L. Dahberg, “Youth Violence in the United States: Major Trends, Risk Factors, and Prevention Approaches,” American Journal of Preventive 

Medicine 14:4 (1998): 259-272.

27 Ibid.

28 An Crabbé, Stef Decoene, and Hans Vertommen, “Profiling Homicide Offenders: A Review of Assumptions and Theories,” Aggression and Violent 

Behavior 13 (2008): 88-106; Matt DeLisi, Andy Hochstetler, Aaron M. Scherer, Aaron Purhmann, and Mark T. Berg, “The Starkweather Syndrome: 

Exploring Criminal History Antecedents of Homicidal Crime Sprees,” Criminal Justice Studies 21:1 (2008): 37-47; Craig Dowden, “Research on Multiple 

Murder: Where Are We in the State of the Art?” Journal of Police and Criminal Psychology 20:2 (2008): 8-18.

29 Gregory Vecchi, Ph.D., Tiffany Hill, and Steve Conlon, FBI Behavioral Science Unit, FBI Academy, Quantico, VA, in discussion, Dec. 14, 2009.
D-5

incorporating this model was quite accurate in its assessment of whether patients fell into a low- or highrisk group for violence .30 Th is software, called Classifi cation of Violence Risk, is available for use with 

acutely hospitalized civil patients,31 and suggests that the development of tools for other populations 

may be worth pursuing . Th e Danger Assessment Tool was created to identify women at risk of being 

killed by their intimate partners, and has had some success at doing so .32 A full academic literature 

review would reveal other tools like these that the Department of Defense might use in part or in whole . 

Th e Department of Defense could also sponsor the development of a comprehensive risk assessment 

tool aimed at identifying those at risk for a wide range of violent behaviors, or for being the victim of 

violence .

30 John Monahan, Henry J . Steadman, Pamela Clark Robbins, Paul Appelbaum, Steven Banks, Th omas Grisso, Kirk Heilbrun, Edward P . Mulvey, Loren 

Roth, and Eric Silver, “An Actuarial Model of Violence Risk Assessment for Persons With Mental Disorders,” Psychiatric Services 56:7 (2005): 810-815 .

31 Monahan et al . 2005 .

32 Jacquelyn C . Campbell, Daniel Webster, Jane Koziol-McLain, Carolyn R . Block, Doris Campbell, Mary Ann Curry, Faye Gary, Judith McFarlane, 

Carolyn Sachs, Phyllis Sharps, Yvonne Ulrich, and Susan A . Wilt, “Assessing Risk Factors for Intimate Partner Homicide,” National Institute of Justice 

Journal 250 (2003): 14-19 .

Appendix D

Literature Review of Risk Factors for Violence
D-6

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Protecting the Force: Lessons from Fort Hood

The Report of the DoD Independent Review

Dr. Anthony C. Cain, PhD., Chief Editor

Captain Donald Gabrielson, U.S. Navy, Assistant Editor

Mr. Benjamin Bryant, Managing Editor

Mr. Thomas Zamberlan, Technical Editor

Mr. James Schwenk, Legal Advisor

Commander John Rickards, U.S. Navy

Commander Shawn Malone, U.S. Navy

Lieutenant Colonel James Clemonts, U.S. Army

Lieutenant Colonel Charlie Underhill, U.S. Air Force

Lieutenant Colonel Heather Kness, U.S. Army

Lieutenant Colonel Matthew Phares, U.S. Marine Corps

Major Jonathan Due, U.S. Army

Major Bryan Price, PhD., U.S. Army