SSV-IA Survey on Sexual Violence - Incident Form (Adults)

OMB No. 1121-0292: Approval Expires 12/31/2007

SSV-IA

FORM
(12-4-2006)

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS

SURVEY ON SEXUAL VIOLENCE, 2006

and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

– Incident Form (Adult)

Economics and Statistics Admin.

U.S. CENSUS BUREAU

Incident Number ___ out of ___
7. Victim #1: What was the victim’s age at the
time of the incident?

1. On what date did the incident occur?
(If more than one date, report the most recent.)
Month Day
Year

01
02
03
04

2. In what facility did the incident occur?

01

City/Place

02
03
04

3. Where did the incident occur? (Mark ( x ) all that apply.)

02
03
04
05
06
07
08
09

In the victim’s cell/room (if the victim and perpetrator
share a cell/room, count as the victim’s cell)
In the perpetrator’s cell/room
In a dormitory or other multiple housing unit
In a common area within a cell block (shower,
dayroom)
In a temporary holding cell within the facility
In a program service area (commissary, kitchen,
storage, laundry, cafeteria, workshop, or hallway)
Outside the facility
While in transit
Other – Specify

05
06
07

01
02

02
03
04

07

35 – 39
40 – 44
45 or older

X

) all that

Male
Female

03
04

Under age 18
18 – 24
25 – 29
30 – 34

05
06
07

35 – 39
40 – 44
45 or older

11. Victim #2: What was the victim’s race/ethnic origin?
(Mark ( x ) all that apply.)

Morning (6 a.m. to noon)
Afternoon (noon to 6 p.m.)
Evening (6 p.m. to midnight)
Overnight (midnight to 6 a.m.)

01
02
03

5. How many victims were involved in the incident?

04
05

Number of victims . . .

06

➔

07

If more than two victims were reported,
report these characteristics in Notes.

White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
Specify

10. Victim #2: What was the victim’s age at the
time of the incident?
02

01

06

9. Victim #2: What was the victim’s gender?

01

4. What time did the incident occur? (Mark (
apply.)

05

8. Victim #1: What was the victim’s race/ethnic origin?
(Mark ( x ) all that apply.)

Name

01

Under age 18
18 – 24
25 – 29
30 – 34

White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
Specify

6. Victim #1: What was the victim’s gender?
01
02

Male
Female

Burden Statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB
control number. The burden of this collection is estimated to average 15 minutes per response, including reviewing instructions, searching
existing data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW,
Washington, DC 20531. Do not send your completed form to this address.

12. Did the victim(s) sustain any physical injury
during the incident?
01

Yes ➔ a. What injuries occurred?
(Mark ( x ) all that apply for all victims.)
01
02
03
04
05
06
07
08

Knife or stab wounds
Broken bones
Anal or vaginal tearing
Teeth chipped or knocked out
Internal injuries
Knocked unconscious
Bruises, black eye, sprains, cuts,
scratches, swelling, welts
Other – Specify

15. After the incident was reported, was the
victim(s) – (Mark ( x ) all that apply for all victims.)

06

Placed in administrative segregation/protective
custody
Placed in a medical unit, ward, or hospital
Confined to own cell/room
Given a higher custody level with the facility
Transferred to another facility
Other – Specify

07

None of the above

01
02
03
04
05

16. What type of sexual violence was involved in
the incident? (See the SSV Summary Form for
definitions.)
b. Did the victim(s) receive medical
treatment for these injuries?
01
02
02

Yes
No

No (No injury sustained)

01
02
03
04

13. Who reported the incident?
(Mark ( x ) all that apply.)
01
02
03
04
05
06
07
08
09
10

Victim
Another inmate (non-victim)
Family of victim
Correctional officer/front line staff
Administrative staff
Medical/healthcare staff
Instructor/teacher
Counselor
Chaplain or other religious official
Other – Specify

Inmate-on-inmate nonconsensual sexual act
→ Complete Section A
Inmate-on-inmate abusive sexual contact
→ Complete Section A
Staff sexual misconduct → Complete Section B
Staff sexual harassment → Complete Section B

Section A – INMATE-ON-INMATE SEXUAL VIOLENCE
17. How many perpetrators were involved in the
incident?
Number of perpetrators . . . .
➔ If more than two perpetrators were involved,
report these characteristics in Notes.
18. Perpetrator #1: What was the perpetrator’s
gender?
01
02

Male
Female

19. Perpetrator #1: What was the perpetrator’s age
at the time of the incident?
14. After the incident was reported, was the
victim(s) – (Mark ( x ) all that apply for all victims.)

01
02

01
02
03
04
05
06

Given a medical examination
Administered a rape kit
Tested for HIV/AIDS
Tested for other sexually transmitted diseases
Provided with counseling or mental health
treatment
None of the above

03
04

05
06
07

35–39
40–44
45 or older

20. Perpetrator #1: What was the perpetrator’s race/
ethnic origin? (Mark ( x ) all that apply.)
01
02
03
04
05
06
07

Page 2

Under age 18
18–24
25–29
30–34

White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic Origin)
Other racial category in your information system –
Specify

FORM SSV-IA (12-4-2006)

Section B – STAFF SEXUAL MISCONDUCT
AND HARASSMENT

21. Perpetrator #2: What was the perpetrator’s
gender?
01
02

Male
Female

26. What was the nature of the incident?
(Mark ( x ) all that apply.)

22. Perpetrator #2: What was the perpetrator’s age
at the time of the incident?
01
02
03
04

Under age 18
18–24
25–29
30–34

05
06
07

35–39
40–44
45 or older

07

Physical force resulting in a nonconsensual
sexual act
Pressure or abuse of power resulting in a
nonconsensual sexual act
Indecent exposure, invasion of privacy, or
voyeurism for sexual gratification
Unwanted touching for sexual gratification
Sexual harassment or repeated verbal statements
of a sexual nature by staff
Sexual relationship between inmate and staff
that appeared to be willing
Other – Specify

08

Level of coercion unknown

01
02
03
04
05

23. Perpetrator #2: What was the perpetrator’s race/
ethnic origin? (Mark ( x ) all that apply.)
01
02
03
04
05
06
07

White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic Origin)
Other racial category in your information system –
Specify

06

27. How many staff were involved in the incident?
Number of staff. . . .
➔ If more than two staff were involved, report
these characteristics in Notes.

24. What type of pressure or physical force was
used by the perpetrator on the victim?
(Mark ( x ) all that apply for all perpetrators.)

09

Persuasion or talked into sexual activity
Bribery or black mail
Gave victim drugs or alcohol
Offered protection from other inmates
Threatened with physical harm
Physically held victim down or restrained in
some way
Physically harmed or injured
Threatened with a weapon
Other – Specify

10

None

01
02
03
04
05
06
07
08

28. Staff #1: What was the gender of the staff?
01
02

Male
Female

29. Staff #1: What was the age of the staff at the
time of the incident?
01
02
03
04

24 or younger
25 – 29
30 – 34
35 – 39

05
06
07

40 – 44
45 – 54
55 or older

25. What sanction was imposed on the perpetrator?
(Mark ( x ) all that apply for all perpetrators.)
01
Placed in solitary confinement or disciplinary
segregation
02
Confined to own cell/room
03
Placed in higher custody level within same facility
04
Transferred to another facility
05
Loss of "good/gain" time or increase in "bad" time
06
Given extra work
07
Loss of privileges
08
Arrested
09
Referred for prosecution
10
Given new sentence
Other – Specify
11

FORM SSV-IA (12-4-2006)

Page 3

30. Staff #1: What was the race/ethnic origin of the
staff involved in the incident? (Mark ( x ) all that
apply.)
01
02
03
04
05
06
07

White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
Specify

35. What was the primary position description of
the staff involved in the incident? (Mark ( x ) all
that apply for all staff involved.)
01

02

07

Clerical including secretaries, clerks,
receptionists, and other administrative support
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
Medical or health care staff, including
counselors, doctors, dentists, psychologists,
psychiatrists, social workers, nurses, and
medical assistants
Education staff, including instructors, teachers,
librarians, and education assistants
Other program staff

08

Other staff – Specify

03
04

05

06

31. Staff #2: What was the gender of the staff?
01
02

Male
Female

Administrator, including wardens,
superintendents, assistants and others in
administrative positions
Correctional officer/supervision staff

32. Staff #2: What was the age of the staff at the
time of the incident?
01
02
03
04

24 or younger
25 – 29
30 – 34
35 – 39

05
06
07

40 – 44
45 – 54
55 or older

36. At the time of the incident, how long had the
staff worked at the facility? (Mark ( x ) all that
apply for all staff involved.)
01
02
03

33. Staff #2: What was the race/ethnic origin of the
staff involved in the incident? (Mark ( x ) all that
apply.)
01
02
03
04
05
06
07

White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
Specify

34. Was the staff involved in the incident an
employee of the facility, a contractor, or a
volunteer? (Mark ( x ) all that apply for all staff
involved.)
01
02
03
04

Less than 6 months
6 months to 1 year
1 to 5 years

04
05

5 to 10 years
More than 10 years

37. What sanction was imposed on the staff?
(Mark ( x ) all that apply for all staff involved.)

08

Reprimanded or disciplined
Demoted or diminished responsibilities
Transferred to another facility
Arrested
Referred for prosecution
Discharged
Staff resigned (prior to completion of investigation)
Staff resigned (after investigation was completed)

09

Other – Specify

01
02
03
04
05
06
07

NOTES

Full or part–time paid employee
Contract employee or vendor
Volunteer or intern
Other – Specify

Page 4

FORM SSV-IA (12-4-2006)