SSV IJ SSV Incident Form Juveniles

OMB No. 1121-0292: Approval Expires xx/xx/xxxx

SSV-IJ

FORM
(3-7-2014)

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 (Juvenile)

Economics and Statistics Admin.

U.S. CENSUS BUREAU

State

Incident Number ___ out of ___
6. How many victims were involved in the incident?

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

Number of victims . . . .
➔ If more than two victims were involved, 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

01
02

Male
Female

03
04

Transgender
Intersex

3. Where did the incident occur? (Mark ( X ) all that apply.)
01

02
03
04
05
06
07
08
09
10
11
12

13

8. Victim #1: What was the victim’s age at the time
of the incident?
In the victim’s cell or room (e.g., if the victim and
perpetrator share a cell or room, count as the victim’s
05
20–24
01
Under the age of 13
cell)
02
13–15
06
25 or older
In the perpetrator’s cell or room
03
16–17
In a dormitory or other multiple housing unit
18–19
04
In a common area (e.g., shower, dayroom, or bathroom)
In a temporary holding cell or admissions area within 9. Victim #1: What was the victim’s race/ethnic origin?
the facility
(Mark ( X ) all that apply.)
In a program service area (e.g., commissary, kitchen,
White (not of Hispanic origin)
01
storage, laundry, cafeteria, workshop, or hallway)
Black (not of Hispanic origin)
02
Instructional area (e.g., classroom, school, library,
Hispanic or Latino
03
conference room)
04
American Indian/Alaska Native (not of Hispanic origin)
Recreation area (e.g., yard, courtyard, gymnasium)
05
Asian (not of Hispanic origin)
Medical area (e.g., Infirmary, health clinic)
06
Native
Hawaiian or Other Pacific Islander
Staff area (office, break room, counselor’s office)
(not
of
Hispanic origin)
Offsite or while in transit
Other racial category in your information system –
07
Other – Specify
Specify
Location unknown

4. Did the incident take place in an area subject to
video monitoring?
01
02
03

Yes
No
Don’t know

5. What time did the incident occur?
(Mark ( X ) all that apply.)
01
02
03
04
05

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

10. Victim #2: What was the victim’s gender?
(See definitions on page 5.)
01
02

Male
Female

03
04

Transgender
Intersex

11. Victim #2: What was the victim’s age at the time
of the incident?
01
02
03
04

Under the age of 13
13–15
16–17
18–19

05
06

20–24
25 or older

Burden Statement
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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. 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 ) 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

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
Placed in or returned to administrative segregation,
protective custody, or disciplinary segregation
02
Placed in a medical unit, ward, or hospital
03
Confined to own cell or room
04
Given a higher custody level/different unit within
the facility
05
Transferred to another facility
06
Transferred to another housing unit or dorm, or
given a single room or cell
07
Separated from perpetrator
08
Issued disciplinary report or loss of privileges
09
Placed in camera room, under closer surveillance,
or increased supervision
10
Other – Specify

11

None of the above

17. What type of sexual violence was involved in
the incident? (See definitions on page 5.)
01
Youth–on–youth nonconsensual sexual act
➔ Complete Section A
02
Youth–on–youth abusive sexual contact
➔ Complete Section A
03
Youth–on–youth abusive sexual harassment
➔ Complete Section A
04
Staff sexual misconduct ➔ Complete Section B
05
Staff sexual harassment ➔ Complete Section B

14. Who reported the incident?
(Mark ( X ) all that apply.)
01
Victim
Another youth (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 religious official
09
Perpetrator
10
Perpetrator’s family or friend
11
Grievance coordinator, grievance process, or
12
ombudsperson
Section A – YOUTH-ON-YOUTH SEXUAL VICTIMIZATION
Attorney or legal guardian (e.g., other than family
13
18. How many perpetrators were involved in the
member)
incident?
Confindential informant, anonymous tip, hot line,
14
or through monitoring (e.g., camera, telephone, or
Number of perpetrators . . . .
mail)
➔ If more than two perpetrators were involved,
Other – Specify
15
report these characteristics in Notes.

Page 2

FORM SSV-IJ (3-7-2014)

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

Male
Female

03
04

Transgender
Intersex

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

Under the age of 13
13–15
16–17

04
05
06

18–19
20–24
25 or older

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
02

Male
Female

03
04

Transgender
Intersex

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

Under the age of 13
13–15
16–17

04
05
06

18–19
20–24
25 or older

25. What was the nature of the incident?
(Mark ( X ) all that apply.)
01 X
02
03
04
05
06
07
08
09

Voluntary sexual contact between youths
Sexual harassment
Indecent exposure, masturbation, or voyeurism
Horseplay
Repeated and unwelcome sexual advances or
requests for sexual favors
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.)
01 X Sexual harassment, sexual innuendo, or
verbal comments
Persuasion or talked into sexual activity
02
03
Surprised the victim with unwanted touching,
grabbing or groping, or victim was asleep
04
Bribery or blackmail
05
Gave victim drugs or alcohol
06
Offered protection from other youth
07
Threatened with physical harm
Physically held victim down or restrained in
08
some way
09
Physically harmed or injured
Threatened with a weapon
10
11
Other – Specify

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

12
None
White (not of Hispanic origin)
Black (not of Hispanic origin)
27. What sanction was imposed on the perpetrator(s)?
Hispanic or Latino
(Mark ( X ) all that apply for all perpetrators.)
American Indian/Alaska Native (not of Hispanic
01
Placed in solitary confinement or disciplinary
origin)
segregation
Asian (not of Hispanic origin)
02
Confined to own cell or room
Native Hawaiian or Other Pacific Islander
03
Placed in higher custody level, restricted unit or
(not of Hispanic Origin)
program, within the same facility
Other racial category in your information system –
04
Transferred to other unit/cell or separated from
Specify
victim
05
Transferred to another facility
06
Loss of "good/gain" time or increase in "bad"
time/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
11
Referred for prosecution or indicted
12
Convicted, given new sentence, or fined
Other – Specify
13

FORM SSV-IJ (3-7-2014)

Page 3

Section B – STAFF-ON-YOUTH SEXUAL ABUSE
28. What was the nature of the incident?
(Mark ( X ) all that apply.)
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
Wrote letters to youth, showed pictures, offered
gifts, or special privileges
Sexual relationship between youth and staff
that appeared to be willing
Other – Specify

01
02
03
04
05
06
07
08

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

02

Female

34. 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

35. 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

Level of coercion unknown

09

Male

07

29. How many staff were involved in the incident?

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

Number of staff . . . . .

➔ If more than two staff were involved, report
these characteristics in Notes.
30. Staff #1: What was the gender of the staff?
01

Male

02

Female

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.)
01
02
03

31. 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

32. 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

04

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

08

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

09

Other staff – Specify

01

02
03
04

05

06
07

Page 4

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

FORM SSV-IJ (3-7-2014)

Definitions

38. What sanction was imposed on the staff?
(Mark ( X ) all that apply for all staff involved.)
01
02
03

04
05

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 outside law enforcement
agency

10

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)

11

Other – Specify

12

No action taken

06
07
08
09

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

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 YOUTH Repeated
and unwelcome sexual advances, requests for sexual favors, or
verbal comments, gestures, or actions of a derogatory or
offensive sexual nature by one youth directed toward another.
STAFF SEXUAL MISCONDUCT Any behavior or act of a
sexual nature directed toward a youth 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
youth 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
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 a
youth 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-IJ (3-7-2014)

Page 5