On November 5, 2009 a gunman opened fire at the Soldier Readiness Center at Fort Hood, Texas. 13 people were killed and 43 others were wounded or injured. The initial response to the incident was prompt and effective. 2 minutes and 40 seconds after the initial 911 call, installation first responders arrived on the scene. One-and-a-half minutes later, the assailant was incapacitated. 2 ambulances and an incident command vehicle from the post hospital arrived on the scene 2 minutes and 50 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 loss. 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 of Defense is prepared for similar incidents in the future - especially multiple, simultaneous incidents. Following the shooting, Defense Secretary Robert Gates established the Department of Defense Independent Review Board Related to Fort Hood, and asked that we lead the effort. Secretary Gates directed us to report with recommendations to identify and address possible deficiencies in: -DoD 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 DoD'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 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, we formed a panel of 5 teams to assist in conducting the review and established an advisory board that included senior representatives from each Service, 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 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 the care he provided to patients during his career. Conducting our review, we have reached a number of conclusions and made several corresponding recommendations; they are reflected in the chapters of this document. In addition to this comprehensive, initial report, the August 18, 2010 Follow on Report is also included in this publication, as Appendix E. These two reports, together, provide the most current information and recommendations from this tragedy.