SSV IA SSV Incident Form Adult

OMB No. 1121-0292: Approval Expires XX/XX/XXXX

SSV-IA

FORM
(3-6-2014)

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2013

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

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

2. In what facility did the incident occur?
Name

7. Victim #1: What was the victim’s gender?
(See definitions on page 5.)

City/Place

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

01

Male

03

Transgender

02

Female

04

Intersex

8. Victim #1: What was the victim’s age at the
time of the incident?

01

In the victim’s cell or room (e.g., if the victim and perpetrator
share a cell or room, count as the victim’s cell)

02

In the perpetrator’s cell or room
In a dormitory or other multiple housing unit

02

In a common area (e.g., shower, dayroom, or bathroom)
In a temporary holding cell or intake area within the
facility
In a program service area (e.g., commissary, kitchen,
storage, laundry, cafeteria, workshop, or hallway)
Instructional area (e.g., classroom, school, library,
conference room)

04

03
04
05
06
07

03

08

Recreation area (e.g., yard, courtyard, gymnasium)

09
10

Medical area (e.g., infirmary, health clinic)
Staff area (e.g., office, break room, or counselor’s office)

11

Offsite or while in transit

12

Other – Specify

13

Location unknown

02
03

Yes
No
Don’t know

5. What time did the incident occur?
(Mark ( X ) all that apply.)
01
Morning (6 a.m. to noon)
02
Afternoon (noon to 6 p.m.)
03
Evening (6 p.m. to midnight)
04
Overnight (midnight to 6 a.m.)
Time unknown
05

Under age 18
18 – 24
25 – 29
30 – 34

05
06
07
08

35 – 39
40 – 44
45 – 54
55 and over

9. Victim #1: What was the victim’s race/ethnic origin?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07

4. Did the incident take place in an area subject to
video monitoring?
01

01

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 gender?
(See definitions on page 5.)
01

Male

03

Transgender

02

Female

04

Intersex

11. Victim #2: What was the victim’s age at the
time of the incident?
05
35 – 39
01
Under age 18
40 – 44
06
02
18 – 24
03
25 – 29
45 – 54
07
30 – 34
04
55 and over
08

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Washington, DC 20531. Do not send your completed form to this address.

12. Victim #2: What was the victim’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

13. Did the victim(s) sustain any physical injury
during the incident?
02
01

No (No injury sustained)
Yes ➔ a. What injuries occurred?
(Mark ( X
x ) all that apply for all victims.)
Knife or stab wounds
01
Broken bones
02
Anal or vaginal tearing
03
Chipped or knocked out teeth
04
Internal injuries
05
Knocked unconscious
06
07
Bruises, black eye, sprains, cuts,
scratches, swelling, welts
08
Other – Specify

➔ b. Did the victim(s) receive medical
treatment for these injuries?
01
Yes
02
No
14. Who reported the incident?
(Mark ( X ) all that apply.)
01
Victim
Another inmate (non-victim)
02
Victim’s family or friend
03
Correctional officer or front line staff
04
Administrative staff
05
Medical, healthcare, or mental health staff
06
Instructor, teacher, or counselor
07
Other staff (e.g., kitchen worker, maintenance)
08
Chaplain or other religion official
09
Perpetrator
10
Perpetrator’s family or friend
11
Grievance coordinator, grievance process, or
12
ombudsperson
Attorney or legal guardian (e.g., other than family member)
13
Confidential informant, anonymous tip, hot line, or
14
through monitoring (e.g., camera, telephone, or mail)
Other – Specify
15

Page 2

15. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
Given a medical examination
02
Administered a rape kit
03
Tested for HIV/AIDS
04
Tested for other sexually transmitted diseases
05
Provided with counseling or mental health
treatment
06
Offered but declined testing or treatment
07
Already released/discharged
08
None of the above
16. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
02
03
04
05
06
07
08

Placed in or returned to administrative segregation,
protective custody, or disciplinary segregation
Placed in a medical unit, ward, or hospital
Confined to own cell or room
Given a higher custody level or different unit within
the facility
Transferred to another facility
Transferred to another housing unit or dorm, or
given a single room or cell
Separated from perpetrator
Issued disciplinary report or loss of privileges

10

Placed in camera room, under closer surveillance,
or increased supervision
Other – Specify

11

None of the above

09

17. What type of sexual violence was involved in
the incident? (See definitions on page 5.)
01
02
03
04
05

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

Section A – INMATE-ON-INMATE SEXUAL VICTIMIZATION
18. How many perpetrators were involved in the
incident?
Number of perpetrators . . . .
Š If more than two perpetrators were involved,
report these characteristics in Notes.

FORM SSV-IA (3-6-2014)

19. Perpetrator #1: What was the perpetrator’s
gender? (See definitions on page 5.)
01
02

Male
Female

03
04

01

Transgender

02

Intersex

03

20. Perpetrator #1: What was the perpetrator’s age
at the time of the incident?
01
02
03

Under age 18
18–24
25–29

04
05
06

30–34
35–39
40–44

25. What was the nature of the incident?
(Mark ( X ) all that apply.)

07
08

45–54
55 and over

04
05
06
07

21. Perpetrator #1: 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

22. Perpetrator #2: What was the perpetrator’s
gender? (See definitions on page 5.)
01

Male

03

Transgender

02

Female

04

Intersex

08
09

01
02
03

Under age 18
18–24
25–29

04
05
06

30–34
35–39
40–44

07
08

45–54
55 and over

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

Unwanted touching for sexual gratification or
abusive sexual contact
Pressure or coercion (without force) resulting in a
nonconsensual sexual act
Physical force (or the threat of force) resulting
in a nonconsensual sexual act
Other – Specify

26. What type of pressure or physical force was
used by the perpetrator on the victim?
(Mark ( X ) all that apply for all perpetrators.)
Sexual harassment, sexual innuendo, or verbal
01
comments
Persuasion or talked into sexual activity
02
03
Surprised the victim with unwanted touching,
grabbing or groping, or victim was asleep
05

Bribery or blackmail
Gave victim drugs or alcohol

06

Offered protection from other inmates

07

11

Threatened with physical harm
Physically held victim down or restrained in
some way
Physically harmed or injured
Threatened with a weapon
Other – Specify

12

None

04

08

23. Perpetrator #2: What was the perpetrator’s age
at the time of the incident?

Voluntary sexual contact between adults
Sexual harassment
Indecent exposure, masturbation, or voyeurism
Horseplay
Repeated and unwelcome sexual advances or
requests for sexual favors

09
10

27. What sanction was imposed on the perpetrator(s)?
White (not of Hispanic origin)
(Mark ( X ) all that apply for all perpetrators.)
Black (not of Hispanic origin)
01
Placed in solitary confinement or disciplinary
Hispanic or Latino
segregation
American Indian/Alaska Native (not of Hispanic
02
Confined to own cell or room
origin)
03
Placed in higher custody level, restricted unit or
Asian (not of Hispanic origin)
program, within the same facility
Native Hawaiian or Other Pacific Islander
04
Transferred
to other unit/cell or separated from victim
(not of Hispanic Origin)
Transferred
to
another facility
05
Other racial category in your information system –
Specify
06
Loss of "good/gain" time, increase in "bad" time or
delayed release
07
Given extra work
08
Loss of privileges, disciplinary report or conduct
violation, or other reprimand
09
Sent to counseling or treatment team
10
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
11
Convicted, given new sentence, or fined
12
Other – Specify
13

FORM SSV-IA (3-6-2014)

Page 3

Section B – STAFF-ON-INMATE SEXUAL
ABUSE
28. What was the nature of the incident?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07
08

09

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

➔ If more than two staff were involved, report
these characteristics in Notes.

Male

02

01
02

04

24 or younger
25 – 29
30 – 34
35 – 39

05
06
07

40 – 44
45 – 54
55 or older

01
03
04
05
06
07

37. What was the primary position description of
the staff involved in the incident?
(Mark ( X ) all that apply for all staff involved.)
01
02

32. Staff #1: What was the race/ethnic origin of the
staff involved in the incident?
(Mark ( X ) all that apply.)
02

04

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

Female

31. Staff #1: What was the age of the staff at the
time of the incident?

03

40 – 44
45 – 54
55 or older

36. 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.)

03

30. Staff #1: What was the gender of the staff?

02

06

Level of coercion unknown

Number of staff . . . .

01

05

Physical force resulting in a nonconsensual
03
07
sexual act
04
Pressure or abuse of power resulting in a
35. Staff #2: What was the race/ethnic origin of the
nonconsensual sexual act
staff involved in the incident?
Indecent exposure, invasion of privacy, or
(Mark ( X ) all that apply.)
voyeurism for sexual gratification
White (not of Hispanic origin)
01
Unwanted touching for sexual gratification
02
Black (not of Hispanic origin)
Sexual harassment or repeated verbal statements
03
Hispanic or Latino
of a sexual nature by staff
American Indian/Alaska Native (not of Hispanic
04
Wrote letters to inmate, showed pictures,
origin)
offered gifts, or special privileges
05
Asian (not of Hispanic origin)
Sexual relationship between inmate and staff
that appeared to be willing
Native Hawaiian or Other Pacific Islander
06
(not of Hispanic origin)
Other – Specify
07
Other racial category in your information system –
Specify

29. How many staff were involved in the incident?

01

24 or younger
25 – 29
30 – 34
35 – 39

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

03
04

05

06
07
08
09

Administrator, including wardens, superintendents,
assistants and others in administrative positions
Correctional officer or supervision staff
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
Volunteers or Interns
Other staff – Specify

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

Male

03

Transgender

02

Female

04

Intersex

Page 4

FORM SSV-IA (3-6-2014)

38. What sanction was imposed on the staff?
(Mark ( X ) all that apply for all staff involved.)
01
02
03
04
05
06
07
08
09
10
11

12

Sent to training or counseling
Reprimanded or disciplined
Demoted or diminished responsibilities, or
temporary suspension
Transferred to another facility or unit
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, sentenced, or fined
Discharged, terminated, or contract not renewed
Staff resigned (prior to completion of investigation)
Staff resigned (after investigation was completed)
Other – Specify

No action taken

39. 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
Less than 6 months
6 months to 1 year
02
1 to 5 years
03
5 to 10 years
04
More than 10 years
05

NOTES

Definitions
Sexual victimization:
NONCONSENSUAL SEXUAL ACTS Sexual contact of any
person without his or her consent, or of a person who is
unable to consent or refuse;
AND
Contact between the penis and the vulva or the penis
and the anus including penetration, however slight; OR
Contact between the mouth and the penis, vulva, or
anus;
OR
Penetration of the anal or genital opening of another person,
however slight, by a hand, finger, object, or other instrument
ABUSIVE SEXUAL CONTACT (less severe) Sexual
contact of any person without his or her consent, or of a
person who is unable to consent or refuse;
AND
Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
of any person:
EXCLUDE
Incidents in which the contact was incidental to a physical
altercation.
SEXUAL HARASSMENT BY ANOTHER INMATE Repeated
and unwelcome sexual advances, requests for sexual favors,
or verbal comments, gestures, or actions of a derogatory or
offensive sexual nature by one inmate directed toward
another.
STAFF SEXUAL MISCONDUCT Any behavior or act of a
sexual nature directed toward an inmate by an employee,
volunteer, contractor, official visitor or other agency
representative (exclude family, friends or other visitors.)
Sexual relationships of a romantic nature between staff and
inmates are included in this definition.
Consensual or nonconsensual sexual acts including:
Intentional touching of the genitalia, anus, groin, breast,
inner thigh, or buttocks that is unrelated to official duties
or with the intent to abuse, arouse, or gratify sexual desire;
OR
Completed, attempted, threatened, or requested sexual acts;
OR
Occurrences of indecent exposure, invasion of privacy, or
staff voyeurism for reasons unrelated to official duties or for
sexual gratification.
STAFF SEXUAL HARASSMENT Repeated verbal
statements, comments or gestures of a sexual nature to an
inmate by an employee, volunteer, contractor, official visitor,
or other agency representative (excludes family, friends, or
other visitors). Demeaning references to gender or derogatory
comments about body or clothing; sexually suggestive;
OR
Repeated profane or obscene language or gestures.
Gender categories:
TRANSGENDER A person whose gender identity (i.e.,
internal sense of feeling male or female) is different from
the person’s assigned sex at birth.
INTERSEX A person whose sexual or reproductive anatomy
or chromosomal pattern does not seem to fit typical
definitions of male or female. Intersex medical conditions
are sometimes referred to as disorders of sex development.

FORM SSV-IA (3-6-2014)

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