SSV1, SSV2, SSV3, Survey of Sexual Victimization forms

Survey of Sexual Victimization

Attachment 3. SSV forms

OMB: 1121-0292

Document [pdf]

Download: pdf | pdf

OMB No. 1121-0292: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-1

FORM
(04-10-2024)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2023
Federal Bureau of Prisons
Summary Form

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE
U.S. CENSUS BUREAU

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

Number and street or P.O. Box/Route Number

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

(Please correct any error in name, mailing address, and ZIP Code)

What facilities are included in this data collection?
All confinement facilities operated by the Federal Bureau of
Prisons.
● INCLUDE prisons, penitentiaries, and correctional
institutions; boot camps; community correction facilities;
halfway houses; prison farms; reception, diagnostic, and
classification centers; road camps; forestry and
conservation camps; vocational training facilities; prison
hospitals; and drug and alcohol treatment facilities for
prisoners.
● EXCLUDE privately-operated facilities. (These
facilities will be contacted directly for data on
sexual victimization.)
What inmates and incidents are included in this
data collection?
Inmates under your custody between January 1, 2023, and
December 31, 2023.
● INCLUDE incidents involving inmates under the
authority, custody, or care of your confinement or
community-based facilities or staff.
● EXCLUDE incidents involving inmates held in
local jails and facilities in other jurisdictions.

Reporting instructions:
●
●

Please complete the entire SSV-1 Form.
If the answer to a question is "not available" or "unknown,"
write "DK" (do not know) in the space provided.
● If the answer to a question is "not applicable," write "NA"
in the space provided.
● If the answer to a question is "none" or "0," write "0" on
the line.
Substantiated incidents of sexual victimization:
● Please complete an Incident Form (Adult, SSV-IA)
for each substantiated incident of sexual victimization.
Returning forms:
●

If you need assistance, please call Greta Clark at the
U.S. Census Bureau toll–free at 1–800–253–2078,
or e-mail [email protected]

●

Please return your completed summary
and substantiated incident forms by November
12, 2024.

●

You may complete these forms online at:
https://ssv.census.gov/

●

MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000

●

FAX (TOLL FREE): 1–888–262–3974

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 60 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.

Section I – INMATE–ON–INMATE SEXUAL VICTIMIZATION
DEFINITIONS

1. Does the Federal Bureau of Prisons record
allegations of inmate-on-inmate SEXUAL
ABUSE?
01

This survey utilizes the PREA standard definitions for types
of sexual victimization. These categories are:
SEXUAL ABUSE

Yes ➔ Do you record all reported
occurrences, or only substantiated
ones?
01
All
02

Sexual abuse of an inmate, detainee, or resident by
another inmate, detainee, or resident includes any of the
following acts, if the victim does not consent, is coerced
into such act by overt or implied threats of violence, or is
unable to consent or refuse:

➔

Substantiated only

Please provide an explanation as to why your
agency does not record inmate-on-inmate
SEXUAL ABUSE allegations, in the space
below, and skip to Item 4.

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;
(2) Contact between the mouth and the penis, vulva, or
anus;
(3) Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument; and
(4) Any other intentional touching, either directly or through
the clothing, of the genitalia, anus, groin, breast, inner
thigh, or the buttocks of another person, excluding
contact incidental to a physical altercation.

2. Between January 1, 2023, and December 31, 2023,
how many allegations of inmate-on-inmate
SEXUAL ABUSE were reported?

SEXUAL HARASSMENT
Number reported . . . . . .

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, detainee, or resident directed toward another.

● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated abuse with the same victim/s
and perpetrator/s involved, count only once.
● Exclude any allegations that were reported as
consensual.
3. Of the allegations reported in Item 2, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)
a. Substantiated . . . . . . .
● The event was investigated and determined to
have occurred, based on a preponderance of the
evidence (28 C.F.R. §115.72).
b. Unsubstantiated . . . . .
● The investigation concluded that evidence was
insufficient to determine whether or not the event
occurred.
c. Unfounded . . . . . . . . . .
● The investigation determined that the event did NOT
occur.
d. Investigation ongoing .
● Evidence is still being gathered, processed
or evaluated, and a final determination has not yet
been made.
e. TOTAL (Sum of Items
3a through 3d) . . . . . . .
● The total should equal the number reported in Item 2.

FORM SSV-1 (04-10-2024)

Page 2

6. Of the allegations reported in Item 5, how
many were — (Please contact the agency or ofﬁce
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

4. Does the Federal Bureau of Prisons record
allegations of inmate-on-inmate SEXUAL
HARASSMENT? (See deﬁnitions on page 2.)
01

Yes

➔ Do you record all reported

allegations or only substantiated
ones?
01

All

Substantiated only

a. Substantiated . . . . . . . .

b. Unsubstantiated . . . . . .

➔ Please provide an explanation as to why

your agency does not record
inmate-on-inmate SEXUAL
HARASSMENT allegations, in the space
below, and skip to Section II.

c. Unfounded . . . . . . . . . .

d. Investigation ongoing . .

e. TOTAL (Sum of Items
6a through 6d) . . . . . . .
● The total should equal the number reported in
Item 5.

5. Between January 1, 2023, and December 31, 2023,
how many allegations of inmate-on-inmate
SEXUAL HARASSMENT were reported?
Number reported

......

FORM SSV-1 (04-10-2024)

Page 3

Section II – STAFF-ON-INMATE SEXUAL VICTIMIZATION
DEFINITIONS

7. Does the Federal Bureau of Prisons record
allegations of STAFF SEXUAL ABUSE?
01

STAFF SEXUAL ABUSE

Yes

➔

Sexual abuse of an inmate, detainee, or resident by a staff
member, contractor, or volunteer includes any of the following
acts, with or without consent of the inmate, detainee, or
resident:
(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

(2) Contact between the mouth and the penis, vulva, or
anus;

➔

Do you record all reported
occurrences, or only substantiated
ones?
01

All

Substantiated only

Please provide an explanation as to why
your agency does not record STAFF
SEXUAL ABUSE allegations, in the space
below, and skip to Item 10.

(3) Contact between the mouth and any body part where
the staff member, contractor, or volunteer has the intent
to abuse, arouse, or gratify sexual desire;
(4) Penetration of the anal or genital opening, however
slight, by a hand, finger, object, or other instrument, that
is unrelated to official duties or where the staff member,
contractor, or volunteer has the intent to abuse, arouse,
or gratify sexual desire;
(5) Any other intentional contact, either directly or through
the clothing, of or with the genitalia, anus, groin, breast,
inner thigh, or the buttocks, that is unrelated to official
duties or where the staff member, contractor, or
volunteer has the intent to abuse, arouse, or gratify
sexual desire;

8. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL ABUSE were reported?
Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated abuse with the same victim/s
and perpetrator/s involved, count only once.

(6) Any attempt, threat, or request by a staff member,
contractor, or volunteer to engage in the activities
described in paragraphs (1)–(5) of this section;
(7) Any display by a staff member, contractor, or volunteer
of his or her uncovered genitalia, buttocks, or breast in
the presence of an inmate, detainee, or resident, and

9. Of the allegations reported in Item 8, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

(8) Voyeurism by a staff member, contractor, or volunteer.
STAFF SEXUAL HARASSMENT
Repeated verbal comments or gestures of a sexual nature to an
inmate, detainee, or resident by a staff member, contractor, or
volunteer, including demeaning references to gender, sexually
suggestive or derogatory comments about body or clothing, or
obscene language or gestures.

a. Substantiated . . . . . . .

b. Unsubstantiated . . . . .

c. Unfounded . . . . . . . . . .

d. Investigation ongoing .
e. TOTAL (Sum of Items
9a through 9d) . . . . . . .
● The total should equal the number reported in
Item 8.

FORM SSV-1 (04-10-2024)

Page 4

10. Does the Federal Bureau of Prisons record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 4.)
01

Yes ➔ Can these allegations be counted
separately from allegations of STAFF
SEXUAL ABUSE?

Yes

➔ Skip to Item 13.

Section III – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
13. What is the total number of substantiated
incidents reported Items 3a, 6a, 9a, and 12a?
Total substantiated
incidents . . . . . . . . . . . .

➔

➔ Please provide an explanation as to why

Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.

your agency does not record STAFF
SEXUAL HARASSMENT allegations, in
the space below, and skip to Item 13.
NOTES

11. Between January 1, 2023, and
December 31, 2023, how many allegations
of STAFF SEXUAL HARASSMENT were
reported?
Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated harassment with the same
victim/s and perpetrator/s involved, count only once.
12. Of the allegations reported in Item 11, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

a. Substantiated

.......

b. Unsubstantiated

.....

c. Unfounded . . . . . . . . . .

d. Investigation ongoing .
e. TOTAL (Sum of Items
12a through 12d) . . . . .
● The total should equal the number reported in
Item 11.

FORM SSV-1 (04-10-2024)

Page 5

OMB No. 1121-0292: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-2

FORM
(04-11-2024)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2023
State Prison Systems
Summary Form

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE
U.S. CENSUS BUREAU

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

Number and street or P.O. Box/Route Number

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

(Please correct any error in name, mailing address, and ZIP Code)

What facilities are included in this data collection?
All State-operated confinement facilities that are intended for
adults but sometimes hold juveniles.
● INCLUDE prisons, penitentiaries, and correctional
institutions; boot camps; community correction facilities;
halfway houses; prison farms; reception, diagnostic, and
classification centers; road camps; forestry and
conservation camps; vocational training facilities; prison
hospitals; and drug and alcohol treatment facilities for
prisoners.
● INCLUDE State-operated local detention facilities in
Alaska, Connecticut, Delaware, Hawaii, Rhode Island,
and Vermont.
● EXCLUDE privately operated facilities and
facilities operated and administered by local
governments. (These facilities will be
contacted directly for data on sexual
victimization.)
● EXCLUDE facilities that hold only juveniles. (These
facilities will be contacted directly for data on sexual
victimization.)
What inmates and incidents are included in this
data collection?
Inmates under your custody between January 1, 2023, and
December 31, 2023.
● INCLUDE incidents involving inmates under the
authority, custody, or care of your confinement or
community-based facilities or staff.

Reporting instructions:
●
●

Please complete the entire SSV-2 Form.
If the answer to a question is "not available" or "unknown,"
write "DK" (do not know) in the space provided.
● If the answer to a question is "not applicable," write "NA"
in the space provided.
● If the answer to a question is "none" or "0," write "0" in
the space provided.
Substantiated incidents of sexual victimization:
● Please complete an Incident Form (Adult, SSV-IA)
for each substantiated incident of sexual victimization.
Returning forms:
● If you need assistance, please call Greta Clark at the
U.S. Census Bureau toll–free at 1–800–253–2078, or
e-mail [email protected]
● Please return your completed summary and
substantiated incident forms by November 12,
2024.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

● EXCLUDE incidents involving inmates held in
local jails and facilities in other jurisdictions.
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 60 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.

Section I – INMATE–ON–INMATE SEXUAL VICTIMIZATION 1. Does your State prison system record
allegations of inmate-on-inmate
SEXUAL ABUSE?
DEFINITIONS
Yes ➔ Do you record all reported
01
This survey utilizes the PREA standard definitions for types
occurrences, or only substantiated
of sexual victimization. These categories are:
ones?
SEXUAL ABUSE
Sexual abuse of an inmate, detainee, or resident by
another inmate, detainee, or resident includes any of the
following acts, if the victim does not consent, is coerced
into such act by overt or implied threats of violence, or is
unable to consent or refuse:

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

➔

All

Substantiated only

Please provide an explanation as to why your
agency does not record inmate-on-inmate
SEXUAL ABUSE allegations, in the space
below, and skip to Item 4.

(2) Contact between the mouth and the penis, vulva, or
anus;
(3) Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument; and
(4) Any other intentional touching, either directly or through
the clothing, of the genitalia, anus, groin, breast, inner
thigh, or the buttocks of another person, excluding
contact incidental to a physical altercation.
SEXUAL HARASSMENT

2. Between January 1, 2023, and December 31, 2023,
how many allegations of inmate-on-inmate
SEXUAL ABUSE were reported?

Number reported . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated abuse with the same victim/s
and perpetrator/s involved, count only once.
● Exclude any allegations that were reported as
consensual.
3. Of the allegations reported in Item 2, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

a. Substantiated

.......

● The event was investigated and determined to
have occurred, based on a preponderance of the
evidence (28 C.F.R. §115.72).
b. Unsubstantiated

.....

● The investigation concluded that evidence was
insufficient to determine whether or not the event
occurred.
c. Unfounded . . . . . . . . . .
● The investigation determined that the event did NOT
occur.
d. Investigation ongoing

● Evidence is still being gathered, processed or evaluated,
and a final determination has not yet been made.
e. TOTAL (Sum of Items
3a through 3d)
......
● The total should equal the number reported in Item 2.

FORM SSV-2 (04-11-2024)

Page 2

4. Does your State prison system record
allegations of inmate-on-inmate SEXUAL
HARASSMENT? (See definitions on page 2.)
01

Yes

➔ Do you record all reported

6. Of the allegations reported in Item 5, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

allegations or only substantiated
ones?

➔

All

Substantiated only

a. Substantiated . . . . . . .

b. Unsubstantiated . . . . .
Please provide an explanation as to why
your agency does not record
inmate-on-inmate SEXUAL
HARASSMENT allegations, in the space
below, and skip to Section II.

c. Unfounded

.........

d. Investigation ongoing . .

e. TOTAL (Sum of Items
6a through 6d) . . . . . . .
● The total should equal the number reported in
Item 5.

5. Between January 1, 2023, and
December 31, 2023, how many allegations of
inmate-on-inmate SEXUAL HARASSMENT were
reported?
Number reported . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated harassment with the same
victim/s and perpetrator/s involved, count only once.
● Exclude any allegations that were reported as
consensual.

FORM SSV-2 (04-11-2024)

Page 3

Section II – STAFF-ON-INMATE SEXUAL VICTIMIZATION

DEFINITIONS

Does your State prison system record
allegations of STAFF SEXUAL ABUSE?
01

Yes

STAFF SEXUAL ABUSE
Sexual abuse of an inmate, detainee, or resident by a staff
member, contractor, or volunteer includes any of the following
acts, with or without consent of the inmate, detainee, or
resident:
02

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

Substantiated only

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL ABUSE allegations, in the space
below, and skip to Item 10.

Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL ABUSE were reported?
Number reported . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated abuse with the same victim/s and perpetrator/s
involved, count only once.

(6) Any attempt, threat, or request by a staff member,
contractor, or volunteer to engage in the activities
described in paragraphs (1)–(5) of this section;

(7) Any display by a staff member, contractor, or volunteer
of his or her uncovered genitalia, buttocks, or breast in
the presence of an inmate, detainee, or resident, and

Of the allegations reported in Item 8, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

(8) Voyeurism by a staff member, contractor, or volunteer.
a. Substantiated . . . . . . .

STAFF SEXUAL HARASSMENT
Repeated verbal comments or gestures of a sexual nature to an
inmate, detainee, or resident by a staff member, contractor, or
volunteer, including demeaning references to gender, sexually
suggestive or derogatory comments about body or clothing, or
obscene language or gestures.

b. Unsubstantiated . . . . .

c. Unfounded

.........

d. Investigation ongoing .
e. TOTAL (Sum of Items
9a through 9d) . . . . . .
● The total should equal the number reported in
Item 8.

FORM SSV-2 (04-11-2024)

Page 4

10. Does your State prison system record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 4.)
01

Yes

➔ Can these allegations be counted

Section III – PRIVATE AND LOCAL ALLEGATIONS
13. Did any of the allegations reported in Items 2,
5, 8, or 11 occur in a privately operated facility?

separately from allegations of
STAFF SEXUAL ABUSE?
01

Yes

➔ Skip to Item 13.

Yes

14. Did any of the allegations reported in Items 2,
5, 8, or 11 occur in a facility operated and
administered by local governments?

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL HARASSMENT allegations, in
the space below, and skip to Item 13.

Yes

No
Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION

15. What is the total number of substantiated
incidents reported in Items 3a, 6a, 9a, and 12a?
Total substantiated
incidents . . . . . . . . . . . . .

➔
11. Between January 1, 2023, and
December 31, 2023, how many allegations
of STAFF SEXUAL HARASSMENT were
reported?

NOTES

Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated harassment with the same victim/s and
perpetrator/s involved, count only once.
12. Of the allegations reported in Item 11, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

a. Substantiated

.......

b. Unsubstantiated . . . . .

c. Unfounded . . . . . . . . . .
d. Investigation ongoing .
e. TOTAL (Sum of Items
12a through 12d) . . . . .
● The total should equal the number reported in
Item 11.

FORM SSV-2 (04-11-2024)

Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.

Page 5

OMB No. 1121-0292: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-3

FORM
(04-11-2024)

SURVEY OF SEXUAL VICTIMIZATION, 2023
Local Jail Jurisdictions
Summary Form

BUREAU OF JUSTICE STATISTICS

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE
U.S. CENSUS BUREAU

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

Number and street or P.O. Box/Route Number

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

(Please correct any error in name, mailing address, and ZIP Code)

What facilities are included in this data collection?

Reporting instructions:
●

All confinement facilities usually operated by a local law
enforcement agency that are intended for adults but
sometimes hold juveniles.

Please complete the entire SSV-3 Form.

●

● INCLUDE all jails and city/county correctional centers
that hold inmates beyond arraignment. Report on ALL
inmates, including those held in separate holding or
lockup areas within your facility.
● INCLUDE multi-jurisdictional facilities (e.g., regional jails).
● INCLUDE special jail facilities (e.g., medical/treatment/
release centers, halfway houses, and work farms).
● EXCLUDE privately-operated jails. (These
facilities will be contacted directly for data on
sexual victimization.)
What inmates and incidents are included in this
data collection?
Inmates under your custody between January 1, 2023, and
December 31, 2023.
● INCLUDE incidents involving inmates under the
authority, custody, or care of your confinement or
community-based facilities or staff.

If the answer to a question is "not available" or "unknown,"
write "DK" (do not know) in the space provided.
● If the answer to a question is "not applicable," write "NA"
in the space provided.
●

Section I: when exact numeric answers are not available,
provide estimates and mark (X) the box beside each
figure.

●

Sections II, III, and IV: if the answer to a question is
"none" or "zero," write "0" on the line.

Substantiated incidents of sexual victimization:
●

Returning forms:
● If you need assistance, please call Greta Clark at the
U.S. Census Bureau toll–free at 1–888–369–3613,
option 2, or e-mail [email protected]
● Please return your completed summary
and substantiated incident forms by
October 29, 2024.
● You may complete these forms online at:
https://ssv.census.gov/
●

● EXCLUDE inmates held in other jurisdictions.

Please complete an Incident Form (Adult, SSV-IA)
for each substantiated incident of sexual victimization.

•

MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
FAX (TOLL FREE): 1–888–262–3974

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 30 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.

Section I – GENERAL INFORMATION

Section II – INMATE-ON-INMATE SEXUAL VICTIMIZATION

1. How many persons under the supervision of your
local jail jurisdiction were —

DEFINITIONS
This survey utilizes the PREA standard definitions for types
of sexual victimization. These categories are:

a. CONFINED in your jail facilities on
December 31, 2023?

SEXUAL ABUSE

● INCLUDE persons on transfer to treatment facilities
but who remain under your jurisdiction.

● INCLUDE persons out to court while under your
jurisdiction.
● INCLUDE persons held for other jurisdictions.

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

● EXCLUDE persons housed in facilities operated by
two or more jurisdictions or those held in
privately-operated jails.

(2) Contact between the mouth and the penis, vulva, or
anus;

● EXCLUDE inmates on AWOL, escape, or long-term
transfer to other jurisdictions.

(3) Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument; and

● EXCLUDE all persons in non-residential
community-based programs run by your jail (e.g.,
electronic monitoring, house arrest, community
service, day reporting, work programs).
Male
Inmates on
December 31, 2023

(4) Any other intentional touching, either directly or through
the clothing, of the genitalia, anus, groin, breast, inner
thigh, or the buttocks of another person, excluding
contact incidental to a physical altercation.

Female
SEXUAL HARASSMENT

b. ADMITTED to your jail facilities during 2023?
● INCLUDE new admissions only, i.e., persons officially
booked into and housed in your facilities by formal legal
document and by the authority of the courts or some
other official agency.
● INCLUDE repeat offenders booked on new charges.
● EXCLUDE returns from escape, work release, medical
appointments/treatment facilities, and bail or court
appearances.
Male

Female

New admissions
during 2023 . . . . . . . . .

2. Between January 1, 2023, and
December 31, 2023, what was the average
daily population of all jail conﬁnement
facilities operated by your jurisdiction?
● To calculate the average daily population, add the
number of persons for each day during the period
January 1, 2023, through December 31, 2023, and
divide the result by 365.
Male

Female

Average daily
population . . . . . . . . . .

FORM SSV-3 (04-11-2024)

Page 2

3. Does your local jail jurisdiction record allegations
of inmate-on-inmate SEXUAL ABUSE?
(See definitions on page 2.)
Yes ➔ Do you record all reported occurrences,
01
or only substantiated ones?

All

Substantiated only

6. Does your local jail jurisdiction record
allegations of inmate-on-inmate SEXUAL
HARASSMENT? (See definitions on page 2.)
01

➔ Please provide an explanation as to why your
agency does not record inmate-on-inmate
SEXUAL ABUSE allegations, in the space
below, and skip to Item 6.

4. Between January 1, 2023, and December 31, 2023,
how many allegations of inmate-on-inmate
SEXUAL ABUSE were reported?

All

Substantiated only

Please provide an explanation as to why your
agency does not record inmate-on-inmate
SEXUAL HARASSMENT allegations, in
the space below, and skip to Section II.

8. Of the allegations reported in Item 7, how many
were —

......

a. Substantiated . . . . . . . .

● The event was investigated and determined to
have occurred, based on a preponderance of the
evidence (28 C.F.R. §115.72).

b. Unsubstantiated . . . . . .

....

c. Unfounded

● The investigation concluded that evidence was
insufficient to determine whether or not the event
occurred.

..........

d. Investigation ongoing

c. Unfounded . . . . . . . . .

e. TOTAL (Sum of Items
8a through 8d) . . . . . . .
● The total should equal the number reported in Item 7.

● The investigation determined that the event did
NOT occur.
.

● Evidence is still being gathered, processed or evaluated,
and a final determination has not yet been made.
e. TOTAL (Sum of Items
5a through 5d) . . . . . . .
● The total should equal the number reported in Item 4.

FORM SSV-3 (04-11-2024)

➔

● Exclude any allegations that were reported as
consensual.

5. Of the allegations reported in Item 4, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)

d. Investigation ongoing

allegations or only substantiated
ones?

● Exclude any allegations that were reported as
consensual.

b. Unsubstantiated

➔ Do you record all reported

7. Between January 1, 2023, and December 31, 2023,
how many allegations of inmate-on-inmate
SEXUAL HARASSMENT were reported?

a. Substantiated

Yes

Page 3

Section III – STAFF-ON-INMATE SEXUAL VICTIMIZATION

9. Does your local jail jurisdiction record
allegations of STAFF SEXUAL ABUSE?

DEFINITIONS

STAFF SEXUAL ABUSE

Yes ➔ Do you record all reported
occurrences, or only substantiated
ones?

Sexual abuse of an inmate, detainee, or resident by a staff
member, contractor, or volunteer includes any of the following
acts, with or without consent of the inmate, detainee, or
resident:
02

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

All

Substantiated only

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL ABUSE allegations, in the space
below, and skip to Item 12.

10. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL ABUSE were reported?

Number reported

......

● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated abuse with the same victim/s and
perpetrator/s involved, count only once.

(6) Any attempt, threat, or request by a staff member,
contractor, or volunteer to engage in the activities
described in paragraphs (1)–(5) of this section;

11. Of the allegations reported in Item 10, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)

(7) Any display by a staff member, contractor, or volunteer
of his or her uncovered genitalia, buttocks, or breast in
the presence of an inmate, detainee, or resident, and
(8) Voyeurism by a staff member, contractor, or volunteer.

a. Substantiated

.......

b. Unsubstantiated

c. Unfounded

.....

..........

d. Investigation ongoing

e. TOTAL (Sum of Items
11a through 11d) . . . . .
● The total should equal the number reported in
Item 10.

FORM SSV-3 (04-11-2024)

Page 4

Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION

12. Does your local jail jurisdiction record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 4.)
01

15. What is the total number of substantiated
incidents reported in Items 5a, 8a, 11a,
and 14a?

Yes ➔ Can these allegations be counted
separately from allegations of
STAFF SEXUAL ABUSE?

Yes

No ➔ Skip to Item 15.

Total substantiated
incidents . . . . . . . . . . . .

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL HARASSMENT allegations, in
the space below, and skip to Item 15.

➔

Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.
NOTES

13. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL HARASSMENT were reported?
Number reported

......

● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated harassment with the same
victim/s and perpetrator/s involved, count only once.
14. Of the allegations reported in Item 13, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)
a. Substantiated . . . . . . .

b. Unsubstantiated . . . . .

c. Unfounded

.........

d. Investigation ongoing

e. TOTAL (Sum of Items
14a through 14d) . . . .
● The number should equal the number reported in
Item 13.

FORM SSV-3 (04-11-2024)

Page 5

OMB No. 1121-0292: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-4

FORM
(04-10-2024)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2023
Other Correctional Facilities
Summary Form

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE
U.S. CENSUS BUREAU

DATA SUPPLIED BY
Title

TELEPHONE
E-MAIL
ADDRESS

Number and street or P.O. Box/Route Number

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

▼▼▼

Name

Area Code

ZIP Code
Number

(Please correct any error in name, mailing address, and ZIP Code)

What facilities are included in this data collection?

•

•
•
•
•
•

PRIVATELY OPERATED FACILITIES: All privately
owned or operated confinement facilities including prisons,
jails, detention centers, community-based facilities, and other
correctional facilities that are intended for adults but
sometimes hold juveniles. INCLUDE privately operated
multi-jurisdictional facilities.
FACILITIES OPERATED BY OR FOR:
THE UNITED STATES MILITARY
THE BUREAU OF IMMIGRATION AND
CUSTOMS ENFORCEMENT
TRIBAL AUTHORITIES
THE BUREAU OF INDIAN AFFAIRS

What inmates and incidents are included in this data
collection?
Inmates under your custody between January 1, 2023, and
December 31, 2023.

•
•

INCLUDE incidents involving inmates under the authority,
custody, or care of your confinement or community-based
facilities or staff.
EXCLUDE inmates held in other jurisdictions.

Reporting instructions:
Please complete the entire SSV-4 Form.
If the answer to a question is "not available" or "unknown,"
write "DK" (do not know) in the space provided.
If the answer to a question is "not applicable," write "NA" in
the space provided.
Section I: when exact numeric answers are not available,
provide estimates and mark X the box beside each
figure.
Sections II, III, and IV: If the answer to a question is "none"
or "zero," write "0" on the line.

•
•
•
•
•

Substantiated incidents of sexual violence:
Please complete an Incident Form (Adult, SSV-IA)
for each substantiated incident of sexual victimization.

•

Returning forms:
If you need assistance, please call the U.S. Census
Bureau toll–free at 1–888–369–3613, option 2,
or e-mail [email protected]
Please return your completed summary and
substantiated incident forms by October
29, 2023.
You may complete these forms online at:
https://ssv.census.gov/

•
•
•
•
•

MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
FAX (TOLL FREE) TO: 1–888–262–3974

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 30 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.

Section II – INMATE-ON-INMATE SEXUAL VICTIMIZATION

Section I – GENERAL INFORMATION
1. How many persons under the supervision of your
facility were —

DEFINITIONS
This survey utilizes the PREA standard definitions for
types of sexual victimization. These categories are:

a. CONFINED on December 31, 2023?
● INCLUDE persons on transfer to treatment
facilities but who remain under your jurisdiction.

SEXUAL ABUSE

● INCLUDE persons held for other jurisdictions.

● EXCLUDE inmates on AWOL, escape, or longterm transfer to other jurisdictions.

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

● EXCLUDE all persons in non-residential
community-based programs run by your facility
(e.g., electronic monitoring, house arrest,
community service, day reporting, work programs).

(2) Contact between the mouth and the penis, vulva, or
anus;

● INCLUDE persons out to court while under your
jurisdiction.

Male
Inmates on
December 31, 2023

(3) Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument; and

Female

b. ADMITTED to your facility during 2023?
SEXUAL HARASSMENT

● INCLUDE new admissions only, i.e., persons
officially booked into and housed in your facilities by
formal legal document and by the authority of the
courts or some other official agency.

● INCLUDE repeat offenders booked on new charges.
● EXCLUDE returns from escape, work release, medical
appointments/treatment facilities, and bail or court
appearances.
Male

Female

New admissions
during 2023 . . . . . . . . .
2. Between January 1, 2023, and
December 31, 2023, what was the average
daily population of your conﬁnement facility?
● To calculate the average daily population, add the
number of persons for each day during the period
January 1, 2023, through December 31, 2023, and
divide the result by 365.
Male

Female

Average daily
population . . . . . . . . . .

FORM SSV-4 (04-10-2024)

Page 2

3. Does your facility record allegations of
inmate-on-inmate SEXUAL ABUSE?
(See definitions on page 2.)
Yes

6. Does your facility record allegations of
inmate-on-inmate SEXUAL HARASSMENT?
(See definitions on page 2.)

➔ Do you record all reported occurrences,

or only substantiated ones?
01

All

Substantiated only

➔ Please provide an explanation as to why your
agency does not record inmate-on-inmate
SEXUAL ABUSE allegations, in the space
below, and skip to item 6.

Yes

➔ Do you record all reported

allegations or only substantiated
ones?

All

Substantiated only

➔ Please provide an explanation as to why your

agency does not record inmate-on-inmate
SEXUAL HARASSMENT allegations, in the
space below, and skip to Section II.

4. Between January 1, 2023, and
December 31, 2023, how many allegations
of inmate-on-inmate SEXUAL ABUSE were
reported?
Number reported . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated abuse with the same victim/s and perpetrator/s
involved, count only once.

7. Between January 1, 2023, and
December 31, 2023, how many allegations of
inmate-on-inmate SEXUAL HARASSMENT
were reported?

● Exclude any allegations that were reported as consensual.
Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated harassment with the same victim/s and
perpetrator/s involved, count only once.

5. Of the allegations reported in Item 4, how many
were — (Please contact the agency or office responsible
for investigating allegations of sexual victimization in order
to fully complete this form.)

● Exclude any allegations that were reported as consensual.
a. Substantiated . . . . . . .
● The event was investigated and determined to have
occurred, based on a preponderance of the evidence
(28 C.F.R. §115.72).
b. Unsubstantiated

8. Of the allegations reported in Item 7, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

....

● The investigation concluded that evidence was insufficient
to determine whether or not the event occurred.
c. Unfounded

.........

● The investigation determined that the event did NOT occur.
d. Investigation ongoing

a. Substantiated . . . . . .

b. Unsubstantiated . . . . .

c. Unfounded . . . . . . . . . .

● Evidence is still being gathered, processed or evaluated,
and a final determination has not yet been made.
d. Investigation ongoing .
e. TOTAL (Sum of Items
5a through 5d) . . . . . .

e. TOTAL (Sum of Items
8a through 8d) . . . . . .

● The total should equal the number reported in Item 4.

● The total should equal the number reported in Item 7.

FORM SSV-4 (04-10-2024)

Page 3

Section III – STAFF-ON-INMATE SEXUAL VICTIMIZATION

9. Does your facility record allegations of STAFF
SEXUAL ABUSE?

DEFINITIONS

Yes

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

Substantiated only

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL ABUSE allegations, in the space
below, and skip to Item 10.

(2) Contact between the mouth and the penis, vulva, or
anus;
(3) Contact between the mouth and any body part where
the staff member, contractor, or volunteer has the intent
to abuse, arouse, or gratify sexual desire;
(4) Penetration of the anal or genital opening, however
slight, by a hand, finger, object, or other instrument, that
is unrelated to official duties or where the staff member,
contractor, or volunteer has the intent to abuse, arouse,
or gratify sexual desire;
(5) Any other intentional contact, either directly or through
the clothing, of or with the genitalia, anus, groin, breast,
inner thigh, or the buttocks, that is unrelated to official
duties or where the staff member, contractor, or
volunteer has the intent to abuse, arouse, or gratify
sexual desire;

10. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL ABUSE were reported?

(6) Any attempt, threat, or request by a staff member,
contractor, or volunteer to engage in the activities
described in paragraphs (1)–(5) of this section;

Number reported . . . . . . .

(7) Any display by a staff member, contractor, or volunteer
of his or her uncovered genitalia, buttocks, or breast in
the presence of an inmate, detainee, or resident, and

● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated abuse with the same victim/s and perpetrator/s
involved, count only once.

11. Of the allegations reported in Item 10, how
many were — (Please contact the agency or
office responsible for investigation allegations of
sexual victimization in order to fully complete this
form.)
a. Substantiated . . . . . . .

b. Unsubstantiated . . . . .

c. Unfounded

.........

d. Investigation ongoing .

e. TOTAL (Sum of Items
11a through 11d) . . . .
● The total should equal the number reported in Item 10.

FORM SSV-4 (04-10-2024)

Page 4

Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION

12. Does your facility record allegations of STAFF
SEXUAL HARASSMENT? (See definitions on page 4.)
01

Yes

➔ Can these allegations be counted

15. What is the total number of substantiated
incidents reported in Items 5a, 8a, 11a,
and 14a?

separately from allegations of
STAFF SEXUAL ABUSE?
01

Yes

No ➔ Skip to Item 15.

Total substantiated
incidents . . . . . . . . . . . . . . .

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL HARASSMENT allegations, in
the space below, and skip to Item 15.

➔ Please complete a Substantiated Incident

Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.

NOTES

13. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL HARASSMENT were reported?

Number reported . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated harassment with the same victim/s and
perpetrator/s involved, count only once.
14. Of the allegations reported in Item 13, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)
a. Substantiated . . . . . . .

b. Unsubstantiated . . . . .

c. Unfounded . . . . . . . . . .

d. Investigation ongoing .

e. TOTAL (Sum of Items
14a through 14d) . . . . .
● The total should equal the number reported in Item 13.

FORM SSV-4 (04-10-2024)

Page 5

OMB No. 1121-0292: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-5

FORM
(03-14-2024)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2023
State Juvenile Systems
Summary Form

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE
U.S. CENSUS BUREAU

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

Number and street or P.O. Box/Route Number

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

(Please correct any error in name, mailing address, and ZIP Code)

What facilities are included in this data collection?
All State-operated juvenile residential placement facilities
used to house juveniles and youthful offenders, regardless of
age or reason for placement.
● INCLUDE State-operated juvenile residential facilities
such as: detention centers, training schools, long-term
secure facilities; reception or diagnostic centers; group
homes or halfway houses; boot camps; ranches; forestry
camps, wilderness or marine programs, or farms;
runaway or homeless shelters; and residential treatment
centers for juveniles.
● EXCLUDE privately operated facilities and
facilities operated or administered by local
governments. (These facilities will be
contacted directly for data on sexual
victimization.)
What persons and incidents are included in this
data collection?
Juveniles and youthful offenders, regardless of age or reason
for placement, under your custody between January 1, 2023,
and December 31, 2023.
● INCLUDE incidents involving juveniles or youthful
offenders under the authority, custody, or care of your
confinement or community-based facilities or staff.
● EXCLUDE incidents involving juveniles or
youthful offenders not held in facilities
operated by your State juvenile system.

Reporting instructions:
●
●

Please complete the entire SSV-5 Form.
If the answer to a question is "not available" or "unknown,"
write "DK" (do not know) in the space provided.
● If the answer to a question is "not applicable," write "NA"
in the space provided.
● Section I: when exact numeric answers are not available,
provide estimates and mark X inside the box beside each
figure.
● Sections II, III, and V: if the answer to a question is
"none" or "zero," write "0" on the line.
Substantiated incidents of sexual violence:
● Please complete an Incident Form (Juvenile, SSV-IJ)
for each substantiated incident of sexual victimization.
Returning forms:
● If you need assistance, please call the U.S. Census
Bureau toll-free at 1–800–253–2078 or email
[email protected]
● Please return your completed summary and
substantiated incident forms by November 12,
2024.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

2. On December 31, 2023, how many persons
held in the facilities reported in Item 1 were —

DEFINITIONS
JUVENILES and YOUTHFUL OFFENDERS
● Any person under the jurisdiction of your State’s juvenile
system or youthful offender authority, regardless of age
or reason for placement.

a. Males . . . . . . . . . . . . . . . . .

FACILITIES

b. Females . . . . . . . . . . . . . . .

INCLUDE all State-operated facilities used to house juveniles
or youthful offenders charged with or court-adjudicated for:

c. TOTAL (Sum of Items 2a and
2b) . . . . . . . . . . . . . . . . . . .

● Any offense that is illegal for both adults and juveniles;

● Count persons held in the facilities reported in Item 1
regardless of age or reason for placement. Include
persons who were temporarily away but had assigned
beds on December 31, 2023.

OR
● An offense that is ILLEGAL in your State for juveniles,
but not for adults (running away, truancy, incorrigibility,
curfew violations, and liquor violations).

3. On December 31, 2023, how many persons
held in the facilities reported in Item 1 were —

EXCLUDE State-operated facilities used ONLY to house
juveniles for:
● Non-criminal purposes (neglect, abuse, abandonment, or
dependency);

a. Age 17 or younger . . . . . .

OR
b. Age 18 to 20 . . . . . . . . . . . . .

● Being Persons in Need of Services (PINS) or Children in
Need of Services (CHINS) who have assigned beds for
reasons other than offenses.

c. Age 21 or older . . . . . . . . . .
d. TOTAL (Sum of Items 3a
through 3c should equal Item
2c) . . . . . . . . . . . . . . . . . . . .

Section I – GENERAL INFORMATION
1. On December 31, 2023, how many facilities
operated by your State held juveniles or
youthful offenders CHARGED WITH or
COURT-ADJUDICATED FOR AN OFFENSE?

Number of facilities

....

● Count all persons held in the facilities reported in Item 1
regardless of age or reason for placement. Include
persons who were temporarily away but had assigned
beds on December 31, 2023.
4. Between January 1, 2023, and December 31, 2023,
how many persons were admitted to or discharged
from the facilities reported in Item 1?

● Count all juvenile residential facilities where young
persons who have committed offenses may be
housed overnight.

a. TOTAL number admitted . . .

● Count each facility with a separate physical location
only once. Do not count separate living/sleeping units,
wings, floors, dorms, barracks, or cottages within a
single facility.

b. TOTAL number discharged .
● Include all persons admitted into your State-operated
juvenile residential facilities by a formal legal document,
by the authority of the courts, or by some other official
agency.
● Include all persons discharged from your
State-operated juvenile residential facilities after a
period of confinement including sentence completion,
pretrial releases, transfers to adult jurisdictions or to
other States, and deaths.
● Exclude admissions and discharges resulting from
returns from escape, administrative transfers to other
juvenile facilities operated by your State, or temporary
release including work/school release, medical
appointments, other treatment facilities, or court
appearances.

FORM SSV-5 (03-14-2024)

Page 2

Section II – YOUTH–ON–YOUTH SEXUAL VICTIMIZATION 5. Does your State juvenile system record

allegations of youth-on-youth SEXUAL ABUSE?

DEFINITIONS

This survey utilizes the PREA standard definitions for types
of sexual victimization. These categories are:

Yes ➔ Do you record all reported
occurrences, or only substantiated
ones?
01

SEXUAL ABUSE

Sexual abuse of a youth, detainee, or resident by
another youth, detainee, or resident includes any of the
following acts, if the victim does not consent, is coerced
into such act by overt or implied threats of violence, or is
unable to consent or refuse:

All
Substantiated only

➔ Please provide an explanation as to why

your agency does not record youth-on-youth
SEXUAL ABUSE allegations, in the space
below, and skip to item 8.

6. Between January 1, 2023, and December 31, 2023,
how many allegations of youth-on-youth SEXUAL
ABUSE were reported?

SEXUAL HARASSMENT
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,
detainee, or resident directed toward another.

● Exclude any allegations that were reported as
consensual.
7. Of the allegations reported in Item 6, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)
a. Substantiated . . . . . . . .
● The event was investigated and determined to have
occurred, based on a preponderance of the evidence
(28 C.F.R. §115.72).
b. Unsubstantiated . . . . . .
● The investigation concluded that evidence was
insufficient to determine whether or not the event
occured.
c. Unfounded . . . . . . . . . .
● The investigation determined that the event did NOT
occur.
d. Investigation ongoing . .
● Evidence is still being gathered, processed or evaluated,
and a final determination has not yet been made.
e. TOTAL (Sum of Items
7a through 7d) . . . . . . .
● The total should equal the number reported in
Item 6.

FORM SSV-5 (03-14-2024)

Page 3

8. Does your State juvenile system record
allegations of youth-on-youth SEXUAL
HARASSMENT? (See definitions on page 3.)
01

Yes

➔ Do you record all reported

allegations or only substantiated
ones?
01
All
02

Substantiated only

➔ Please provide an explanation as to why

your agency does not record youth-on-youth
SEXUAL HARASSMENT allegations, in
the space below, and skip to Section III.

9. Between January 1, 2023, and
December 31, 2023, how many allegations of
youth-on-youth SEXUAL HARASSMENT were
reported?
Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation
included repeated harassment with the same
victim/s and perpetrator/s involved, count only
once.
● Exclude any allegations that were reported as
consensual.
10. Of the allegations reported in Item 9, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)

a. Substantiated . . . . . .

b. Unsubstantiated . . . .

c. Unfounded . . . . . . . . .

d. Investigation ongoing .
e. TOTAL (Sum of Items
10a through 10d) . . . . .
● The total should equal the number reported in
Item 9.
FORM SSV-5 (03-14-2024)

Page 4

Section III – STAFF-ON-YOUTH
SEXUAL VICTIMIZATION

11. Does your State juvenile system record
allegations of STAFF SEXUAL ABUSE?

DEFINITIONS

Yes

STAFF SEXUAL ABUSE
Sexual abuse of a youth, detainee, or resident by a staff
member, contractor, or volunteer includes any of the following
acts, with or without consent of the youth, detainee, or resident:
02

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

Substantiated only

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL ABUSE allegations, in the space
below, and skip to Item 14.

12. Between January 1, 2023, and
December 31, 2023, how many allegations
of STAFF SEXUAL ABUSE were reported?

(5) Any other intentional contact, either directly or through
the clothing, of or with the genitalia, anus, groin, breast,
inner thigh, or the buttocks, that is unrelated to official
duties or where the staff member, contractor, or
volunteer has the intent to abuse, arouse, or gratify
sexual desire;
(6) Any attempt, threat, or request by a staff member,
contractor, or volunteer to engage in the activities
described in paragraphs (1)–(5) of this section;
(7) Any display by a staff member, contractor, or volunteer
of his or her uncovered genitalia, buttocks, or breast in
the presence of a youth, detainee, or resident, and

Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated abuse with the same victim/s and perpetrator/s
involved, count only once.
13. Of the allegations reported in Item 12, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)

(8) Voyeurism by a staff member, contractor, or volunteer.
a. Substantiated . . . . . . .
STAFF SEXUAL HARASSMENT
Repeated verbal comments or gestures of a sexual nature to a
youth, detainee, or resident by a staff member, contractor, or
volunteer, including demeaning references to gender, sexually
suggestive or derogatory comments about body or clothing, or
obscene language or gestures.

b. Unsubstantiated . . . . .

c. Unfounded . . . . . . . . . .

d. Investigation ongoing .

e. TOTAL (Sum of Items
13a through 13d) . . . . .
● The total should equal the number reported in
Item 12.

FORM SSV-5 (03-14-2024)

Page 5

Section IV – PRIVATE AND LOCAL ALLEGATIONS
14. Does your State juvenile system record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 5.)
01

Yes

17. Did any of the allegations reported in Items 6,
9, 12, or 15 occur in a privately operated
facility?

➔ Can these allegations be counted
separately from allegations of
STAFF SEXUAL HARASSMENT?
01

Yes

18. Did any of the allegations reported in Items 6,
9, 12, or 15 occur in a facility operated or
administered by local governments?

➔ Skip to Item 17.

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL HARASSMENT allegations, in
the space below, and skip to Item 17.

Yes

Section V – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
19. What is the total number of substantiated
incidents reported in Items 7a, 10a, 13a,
and 16a?
Total substantiated
incidents . . . . . . . . . . . . .

➔ Please complete a Substantiated Incident Form
(Juvenile, SSV-IJ) for each substantiated
incident of sexual victimization.

15. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL HARASSMENT were reported?

NOTES

Number reported . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated harassment with the same victim/s and
perpetrator/s involved, count only once.
16. Of the allegations reported in Item 15, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)
a. Substantiated . . . . . . .

b. Unsubstantiated . . . . .

c. Unfounded . . . . . . . . . .

d. Investigation ongoing .
e. TOTAL (Sum of Items
16a through 16d) . . . . .
● The total should equal the number reported in
Item 15.

FORM SSV-5 (03-14-2024)

Page 6

OMB No. 1121-0292: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-6

FORM
(04-02-2024)

SURVEY OF SEXUAL VICTIMIZATION, 2023
Locally or Privately-Operated Juvenile Facilities
Summary Form

BUREAU OF JUSTICE STATISTICS

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE
U.S. CENSUS BUREAU

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

Number and street or P.O. Box/Route Number

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

(Please correct any error in name, mailing address, and ZIP Code)

What facilities are included in this data collection?
All juvenile residential placement facilities operated or
administered by a local government and all privately owned or
operated facilities that are used to house juveniles and
youthful offenders, regardless of age or reason for placement.
● INCLUDE locally-operated juvenile residential facilities;
privately owned or operated juvenile residential facilities;
detention centers, training schools, long-term secure
facilities; reception or diagnostic centers; group homes or
halfway houses; boot camps; ranches; forestry camps,
wilderness or marine programs, or farms; runaway or
homeless shelters; and residential treatment centers for
juveniles.
● EXCLUDE State operated juvenile residential
facilities. (These facilities will be contacted
directly for data on sexual victimization.)

Reporting instructions:
●
●
●

Please complete the entire SSV-6 Form.
If the answer to a question is "not available" or "unknown,"
write "DK" (do not know) in the space provided.
If the answer to a question is "not applicable," write "NA"
in the space provided.

●

Section I: when exact numeric answers are not available,
provide estimates and mark (X) the box beside each
figure.

●

Sections II, III, and V: if the answer to a questions "none"
or "zero," write "0" on the line.

Substantiated incidents of sexual violence:
● Please complete an Incident Form (Juvenile, SSV-IJ)
for each substantiated incident of sexual victimization.
Returning forms:

What persons and incidents are included in this
data collection?
Juveniles and youthful offenders, regardless of age or
reason for placement, under your custody between
January 1, 2023, and December 31, 2023.
● INCLUDE incidents involving juveniles or youthful
offenders under the authority, custody, or care of your
confinement or community-based facilities or staff.
● EXCLUDE incidents involving juveniles or
youthful offenders held in facilities operated
by your State juvenile system.

● If you need assistance, please call the U.S. Census
Bureau toll–free at 1–888–369–3613, option 2, or
e-mail [email protected]
● Please return your completed summary and
substantiated incident forms by
November 12, 2024.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

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 30 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.

DEFINITIONS

3. On December 31, 2023, how many persons
held in this facility were —

JUVENILES and YOUTHFUL OFFENDERS
● Any person under the custody or care of a juvenile
residential facility owned or operated by a local
government or private agency.

a. Males

................

FACILITIES

b. Females

INCLUDE all juvenile residential placement facilities operated
or administered by a local government and all privately owned
or operated facilities that are used to house juveniles and
youthful offenders charged with or court-adjudicated for:

c. TOTAL (Sum of Items 3a and
3b) . . . . . . . . . . . . . . . . . . . .

● Any offense that is illegal for both adults and juveniles;

..............

● Count persons held in the facility regardless of age or
reason for placement. Include persons who were
temporarily away but had assigned beds on
December 31, 2023.

OR
● An offense that is ILLEGAL in your State for juveniles,
but not for adults (running away, truancy, incorrigibility,
curfew violations, and liquor violations).

4. On December 31, 2023, how many persons
held in this facility were —

EXCLUDE all State-operated facilities and locally or
privately-operated facilities used ONLY to house juveniles for:
a. Age 17 or younger

● Non-criminal behavior (neglect, abuse, abandonment, or
dependency);
OR

b. Age 18 to 20

● Being Persons in Need of Services (PINS) or Children in
Need of Services (CHINS) who have assigned beds for
reasons other than offenses.

d. TOTAL (Sum of Items 4a
through 4c should equal
Item 3c) . . . . . . . . . . . . . .

1. Is this facility owned by a
Private agency

Native American Tribal Government

State

County

Local or municipal government

Other – Specify

...........

c. Age 21 or older . . . . . . . . .

Section I – GENERAL INFORMATION

......

● Count all persons held in the facility regardless of age
or reason for placement. Include persons who were
temporarily away but had assigned beds on
December 31, 2023.
5. Between January 1, 2023, and
December 31, 2023, how many persons were
admitted to or discharged from this facility?

a. TOTAL number admitted

2. Is this facility operated by a
01

Private agency

Native American Tribal Government

State

County

Local or municipal government

Other – Specify

b. TOTAL number discharged .
● Include all persons admitted to this facility by a formal
legal document, by the authority of the courts, or by
some other official agency.
● Include all persons discharged from this facility after a
period of confinement including sentence completion,
pretrial releases, transfers to adult jurisdictions or to
other States, and deaths.
● Exclude admissions and discharges resulting from
returns from escape, administrative transfers to other
juvenile facilities, or temporary release including
work/school release, medical appointments, other
treatment facilities, or court appearances.

FORM SSV-6 (04-02-2024)

Page 2

Section II – YOUTH-ON-YOUTH SEXUAL VICTIMIZATION

6. Does your facility record allegations of
youth-on-youth SEXUAL ABUSE?

DEFINITIONS

This survey utilizes the PREA standard definitions for
types of sexual victimization. These categories are:

Yes ➔ Do you record all reported
occurrences, or only substantiated
ones?
01

SEXUAL ABUSE

All
Substantiated only

➔ Please provide an explanation as to why your
agency does not record youth-on-youth
SEXUAL ABUSE allegations, in the space
below, and skip to item 9.

7. Between January 1, 2023 and December 31, 2023,
how many allegations of youth-on-youth SEXUAL
ABUSE were reported?
Number reported . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated abuse with the same victim/s and perpetrator/s
involved, count only once.

● Exclude any allegations that were reported as consensual.
8. Of the allegations reported in Item 7, how many
were — (Please contact the agency or office responsible
for investigating allegations of sexual victimization in order
to fully complete this form.)

a. Substantiated

......

● The event was investigated and determined to have
occurred, based on a preponderance of the evidence
(28 C.F.R. §115.72).
b. Unsubstantiated

....

● The investigation concluded that evidence was insufficient
to determine whether or not the event occurred.
c. Unfounded . . . . . . . . .
● The investigation determined that the event did NOT occur.
d. Investigation ongoing

● Evidence is still being gathered, processed or evaluated,
and a final determination has not yet been made.
e. TOTAL (Sum of Items
8a through 8d) . . . . . . .
● The total should equal the number reported in Item 7.

FORM SSV-6 (04-02-2024)

Page 3

9. Does your facility record allegations of
youth-on-youth SEXUAL HARASSMENT?
(See definitions on page 3.)
01

Yes

➔ Do you record all reported

allegations or only substantiated
ones?
01

All

Substantiated only

a. Substantiated . . . . . .

b. Unsubstantiated . . . .

➔ Please provide an explanation as to why

your agency does not record youth-on-youth
SEXUAL HARASSMENT allegations, in
the space below, and skip to Section III.

c. Unfounded

........

d. Investigation ongoing . .

e. TOTAL (Sum of Items
11a through 11d) . . . .
● The total should equal the number reported in Item 10.

10. Between January 1, 2023, and
December 31, 2023, how many allegations of
youth-on-youth SEXUAL HARASSMENT were
reported?
Number reported . . . . . . . .
● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated harassment with the same victim/s and
perpetrator/s involved, count only once.
● Exclude any allegations that were reported as consensual.

FORM SSV-6 (04-02-2024)

Page 4

Section III – STAFF-ON-YOUTH
SEXUAL VICTIMIZATION

12. Does your facility record allegations of STAFF
SEXUAL ABUSE?

DEFINITIONS

Yes

(1) Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

Substantiated only

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL ABUSE allegations, in the space
below, and skip to Item 15.

13. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL ABUSE were reported?

Number reported . . . . . . . .

(6) Any attempt, threat, or request by a staff member,
contractor, or volunteer to engage in the activities
described in paragraphs (1)–(5) of this section;

● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated abuse with the same victim/s and perpetrator/s
involved, count only once.

(7) Any display by a staff member, contractor, or volunteer
of his or her uncovered genitalia, buttocks, or breast in
the presence of a youth, detainee, or resident, and

14. Of the allegations reported in Item 13, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)

(8) Voyeurism by a staff member, contractor, or volunteer.
STAFF SEXUAL HARASSMENT
Repeated verbal comments or gestures of a sexual nature to a
youth, detainee, or resident by a staff member, contractor, or
volunteer, including demeaning references to gender, sexually
suggestive or derogatory comments about body or clothing, or
obscene language or gestures.

a. Substantiated . . . . . .

b. Unsubstantiated . . . .

c. Unfounded . . . . . . . . .

d. Investigation ongoing .

e. TOTAL (Sum of Items
14a through 14d) . . . . .
● The total should equal the number reported in Item 13.

FORM SSV-6 (04-02-2024)

Page 5

Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION

15. Does your facility record allegations of STAFF
SEXUAL HARASSMENT? (See definitions on page 5.)
Yes

➔ Can these allegations be counted

18. What is the total number of substantiated
incidents reported in Items 8a, 11a, 14a,
and 17a.

separately from allegations of
STAFF SEXUAL ABUSE?
01

Yes

➔ Skip to Item 18

Total substantiated
incidents . . . . . . . . . . . .

➔ Please provide an explanation as to why

your agency does not record STAFF
SEXUAL HARASSMENT allegations, in
the space below, and skip to Item 18.

➔ Please complete a Substantiated Incident Form
(Juvenile, SSV-IJ) for each substantiated
incident of sexual victimization.

NOTES

16. Between January 1, 2023, and
December 31, 2023, how many allegations of
STAFF SEXUAL HARASSMENT were reported?

Number reported

.....

● If the allegation involved multiple victims and/or
perpetrators, count only once. If an allegation included
repeated harassment with the same victim/s and
perpetrator/s involved, count only once.
17. Of the allegations reported in Item 16, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)
a. Substantiated

......

b. Unsubstantiated

....

c. Unfounded . . . . . . . . .

d. Investigation ongoing
e. TOTAL (Sum of Items
17a through 17d) . . . . .
●

The total should equal the number reported in Item 16.

FORM SSV-6 (04-02-2024)

Page 6

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

SSV-IA

U.S. DEPARTMENT OF JUSTICE

FORM
(04-10-2024)

SURVEY OF SEXUAL VICTIMIZATION, 2023

BUREAU OF JUSTICE STATISTICS
and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

Substantiated Incident Form (Adult)

U.S. CENSUS BUREAU

Incident Number ___ out of ___
1. Did the incident include repeated behaviors?
01

Yes

4. Did the incident take place in an area subject
to video monitoring? (Mark all that apply.)

If "Yes" ➔ a. On approximately, how many
different dates did it occur? . . .

➔ b. On what date did the most

If "No" ➔ a. On what date did the incident
occur?
Month
Day
Year

2. In what facility did the incident occur?
Name
State

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

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

In the perpetrator’s cell or room
In a dormitory or other multiple housing unit
In a common area (e.g., shower, dayroom, 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, hallway)
In an instructional area (e.g., classroom, school, library,
conference room)

03
04
05
06
07
08

In a recreation area (e.g., yard, courtyard, gymnasium)

09
10

In a medical area (e.g., infirmary, health clinic)
In a staff area (e.g., office, break room, counselor’s office)

Offsite or while in transit

Other – Specify

Location unknown
Location not applicable (e.g., involved written, phone,
or virtual communication)

Unknown

5. What time did the incident occur?
(Mark all that apply.)
01
Morning (6 a.m. to 11:59 a.m.)
02
Afternoon (noon to 5:59 p.m.)
03
Evening (6 p.m. to 11:59 p.m.)
04
Overnight (midnight to 5:59 a.m.)
05
Time unknown

recent incident occur?
Month
Day
Year

City

Yes
No

6. Who reported the incident?
(Mark all that apply.)
01
Victim
02
Another inmate (non-victim)
03
Victim’s family, friend, or legal guardian
04
Correctional officer or front-line staff
05
Administrative staff
06
Medical, healthcare, or mental health staff
07
Instructor, teacher, or counselor
08
Other staff (e.g., kitchen worker, maintenance staff)
09
Chaplain or other religion official
10
Perpetrator
11
Perpetrator’s family, friend, or legal guardian
12
Grievance coordinator, grievance process, or ombuds
13
Attorney (victim’s or perpetrator’s)
14
Confidential informant, anonymous tip, hotline, or
through monitoring (e.g., camera, telephone, or mail)
15
Other – Specify

7. What was the type of sexual victimization incident?
(See definitions on page 9.)
01
Inmate-on-inmate sexual abuse
➞ Complete sections A and B
02
Inmate-on-inmate sexual harassment
➞ Complete sections A and B
03
Staff-on-inmate sexual abuse
➞ Complete sections A and C
04
Staff-on-inmate sexual harassment
➞ Complete sections A and C

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 30 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.

Section A – VICTIMS OF SEXUAL VICTIMIZATION
8. How many victims were involved in the
incident?
Number of victims . . . .
➔ If more than two victims were involved,
please complete this form online.
9. Victim #1: What was the victim’s sex assigned
at birth?
Sex is a multidimensional construct based on a cluster of
anatomical and physiological traits that include external
genitalia, secondary sex characteristics, gonads,
chromosomes, and hormones.
01
Male
02

Female

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
differences in sex development.]

10. Victim #1: What was the victim’s gender
identity?
Gender identity is a person’s core internal understanding
or sense of who they are regardless of sex assigned at
birth.
01
Male
02
03
04

14. Victim #1: Was the victim identiﬁed as having
any of the following disabilities at the time
of the incident? (Mark all that apply.)
Disability is defined as (a) A physical or mental impairment
that substantially limits one or more of the major life
activities of [an] individual; (b) a record of such an
impairment; or (c) being regarded as having such an
impairment.
01

A serious and persistent mental illness (e.g., bipolar
disorder, major depression, obsessive compulsive
disorder, post-traumatic stress disorder, schizophrenia,
etc.)
A cognitive impairment or intellectual disability (e.g.,
ADHD, autism spectrum disorder, dementia, a learning
disability, etc.)
A physical impairment or disability (e.g., back or spinal
injury, blindness or low vision, deafness or hearing loss,
diabetes, epilepsy, heart disease, mobility impairments,
etc.)

15. Victim #1: Did the victim sustain any physical
injury during the incident?
01
Yes 02
No 03
Unknown
If "Yes" ➔ a. What injuries occurred?
(Mark all that apply.)

Female
Transgender [A person whose gender identity is
different from the person’s sex assigned at birth.]

01
02
03

Gender nonconforming [A person whose gender
identity does not conform to traditional societal
gender expectations.]

04
05
06

05
06

Other – Specify
Unknown

07
08
09
10

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

➔ b. Did the victim receive medical

treatment for these injuries?
Yes 02
No 03
Unknown

12. Victim #1: What was the victim’s race or
ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

16. Victim #1: After the incident was reported,
was the victim – (Mark all that apply.)
01
02
03
04
05
06
07

13. Victim #1: What was the victim’s citizenship?
01
02
03

Page 2

A U.S. citizen
Not a U.S. citizen
Of unknown citizenship status

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

08
09

Provided with counseling or mental health treatment
Given a medical examination
Administered a sexual assault kit
Given post-exposure prophylaxis (PEP)
and/or emergency contraception
Tested for HIV/AIDS
Tested for other sexually transmitted infections
Offered but declined testing or treatment and/or
counseling
Already released/discharged
None of the above

FORM SSV-IA (04-10-2024)

Section A – VICTIMS OF SEXUAL VICTIMIZATION
17. Victim #1: After the incident was reported,
was the victim – (Mark all that apply.)

Separated from perpetrator
Confined to own cell or room
Placed in or returned to restrictive housing
Placed in a medical unit, ward, or hospital
Placed in camera room, under close surveillance,
or increased supervision
Transferred to another housing unit or dorm, or
given a single room or cell
Given a higher custody level or different unit within
the facility
Transferred to another facility
Issued disciplinary report or loss of privileges
Other – Specify

None of the above

01
02
03
04
05
06
07
08
09

➔ If there were no other victims, please skip

to Section B on pages 4-5 if the incident
involved an inmate perpetrator or Section C
on pages 6-7 if the incident involved a staff
perpetrator.

22. Victim #2: What was the victim’s citizenship?
01
02
03

23. Victim #2: Was the victim identiﬁed as having
any of the following disabilities at the time
of the incident? (Mark all that apply.)
01

Male

Female

Male

Female

Transgender

Gender nonconforming

Intersex

03
05

06
07

Other – Specify

08
09

Unknown

21. Victim #2: What was the victim’s race or
ethnicity? (Mark all that apply.)

05
06
07
08

Unknown

treatment for these injuries?
Yes 02
No 03
Unknown

25. Victim #2: After the incident was reported,
was the victim – (Mark all that apply.)
01
02
03
04
05
06
07
08
09

FORM SSV-IA (04-10-2024)

➔ b. Did the victim receive medical

years

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

Yes

A physical impairment or disability (e.g., back or spinal
injury, blindness or low vision, deafness or hearing loss,
diabetes, epilepsy, heart disease, mobility impairments,
etc.)

If "Yes" ➔ a. What injuries occurred?
(Mark all that apply.)

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

24. Victim #2: Did the victim sustain any physical
injury during the incident?

18. Victim #2: What was the victim’s sex assigned
at birth?
01

A U.S. citizen
Not a U.S. citizen
Of unknown citizenship status

Page 3

26. Victim #2: After the incident was reported,
was the victim – (Mark all that apply.)

None of the above

01
02
03
04
05
06
07
08
09

28. What types of pressure, coercion, or force
occurred as part of the incident?
(Mark all that apply.)
01
02
03
04
05
06
07

Persuasion or talked into sexual activity
Bribery or blackmail
Gave the victim drugs or alcohol
Offered protection from other inmates
Threats made (e.g., threatened harm to victim or
victim’s family, threatened with a weapon)
Unwanted touching, grabbing, or groping of the victim by
surprise or while the victim was asleep or incapacitated
Physically held victim down or restrained in some way,
including having other inmates restrain the victim

Physical harm or injury

Other – Specify

None of the above

29. How many inmate perpetrators were involved
in the incident?
Section B – INMATE PERPETRATORS OF
SEXUAL VICTIMIZATION
➔ If the perpetrator was a staff member, go to

Section C on pages 6-7.

27. What was the nature of the incident?
(Mark all that apply.)
01
02
03
04

05
06
07

Repeated verbal comments or gestures of a
derogatory or offensive sexual nature
Repeated and unwelcome sexual advances or
requests for sexual favors
Indecent exposure, masturbation, voyeurism, or
other actions of a derogatory sexual nature
Intentional and non-consensual or coerced touching
of the genitalia, anus, groin, breast, inner thigh,
or the buttocks
Nonconsensual sexual act that resulted from
pressure or coercion (without force)
Nonconsensual sexual act that resulted from
physical force (or the threat of force)
Other – Specify

Number of inmate perpetrators . . . .
➞ If more than two inmate perpetrators were
involved, please complete this form online.
30. Perpetrator #1: What was the inmate perpetrator’s
sex assigned at birth?
Sex is a multidimensional construct based on a cluster of
anatomical and physiological traits that include external
genitalia, secondary sex characteristics, gonads,
chromosomes, and hormones.
01
Male
02

Female

31. Perpetrator #1: What was the inmate perpetrator’s
gender identity?
Gender identity is a person’s core internal understanding
or sense of who they are regardless of sex assigned at
birth.
01

Male

Female
Transgender [A person whose gender identity is
different from the person’s sex assigned at birth.]

03
04

Gender nonconforming [A person whose gender
identity does not conform to traditional societal
gender expectations.]

Other – Specify
Unknown

Page 4

FORM SSV-IA (04-10-2024)

32. Perpetrator #1: What was the inmate
perpetrator’s age at the time of the incident?
years
33. Perpetrator #1: What was the inmate
perpetrator’s race or ethnicity?
(Mark all that apply.)
01
02
03
04
05
06
07
08

36. Perpetrator #2: What was the inmate
perpetrator’s gender identity?
(See definitions on page 9.)
01

Male

Female

Transgender

Gender nonconforming

14
15

Other – Specify

09
10
11
12
13

04
05
06
07
08

01
02
03
04
05
06
07

35. Perpetrator #2: What was the inmate
perpetrator’s sex assigned at birth?
01

Male

Female

FORM SSV-IA (04-10-2024)

Loss of "good/gain" time, increase in "bad" time or
delayed release
Given extra work
Loss of privileges, disciplinary report or conduct
violation, or other reprimand
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, given new sentence, or fined
Awaiting a legal outcome

Other – Specify

skip to Notes on page 8 (if applicable) or
submit form.

39. Perpetrator #2: After the incident, was the inmate
perpetrator – (Mark all that apply.)

➔ If there were no other perpetrators, please

Unknown

38. Perpetrator #2: What was the inmate
perpetrator’s race or ethnicity?
(Mark all that apply.)

years

Other – Specify

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

34. Perpetrator #1: After the incident, was the
inmate perpetrator – (Mark all that apply.)
01
Confined to own cell or room
02
Placed in or returned to restrictive housing
Placed in higher custody level, restricted unit or
03
program, within the same facility
04
Transferred to other unit/cell or separated from victim
05
Transferred to another facility
06
Sent to counseling or mental health treatment
07
Given medical treatment or testing
(e.g., post-exposure prophylaxis (PEP), HIV/AIDS)

11
12
13

Intersex

Page 5

Section C – STAFF PERPETRATORS OF
SEXUAL VICTIMIZATION
➔ If the perpetrator was an inmate, go to

Section B on pages 4-5.

40. What was the nature of the incident?
(Mark all that apply.)
01
02
03

04
05
06
07
08
09

Repeated suggestive, derogatory, or obscene verbal
comments or gestures of a sexual nature
Wrote letters, showed pictures, talked on the phone, or
through video conferencing
Exhibited grooming or manipulative behaviors such
as providing gifts, special privileges, or favors to
inmates
Indecent exposure, invasion of privacy, or voyeurism
Any attempt, threat, or request related to abusive
sexual contact or sexual acts
Any touching or kissing for sexual gratification
Pressure or abuse of power resulting in a sexual act
Physical force resulting in a sexual act
Other – Specify

45. Staff #1: Was the staff perpetrator involved in
the incident –
01
02
03
04

46. Staff #1: What was the primary position
description of the staff perpetrator involved in
the incident?
01
02

04
05

09
10

Other staff – Specify

Number of staff . . . .

Correctional officer, supervisory or security staff, or
direct care staff
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
Medical or healthcare staff, including counselors,
doctors, dentists, psychologists, psychiatrists, social
workers, nurses, and medical assistants
Education staff, including instructors, teachers,
librarians, and education assistants
Member of the clergy or chaplaincy
Administrator, including wardens, superintendents,
assistants and others in administrative positions
Clerical staff including secretaries, clerks,
receptionists, and other administrative support
Other program staff
Volunteers or interns

41. How many staff perpetrators were involved in
the incident?

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

➞ If more than two staff were involved, report
please complete this form online.
42. Staff #1: What was the staff perpetrator’s
gender?
01

Male

Female

43. Staff #1: What was the staff perpetrator’s age
at the time of the incident?
years
44. Staff #1: What was the staff perpetrator’s race
or ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

47. Staff #1: At the time of the incident, how long
had the staff perpetrator worked at the
facility?
01
Less than 6 months
02
6 months to 1 year
03
1 to 5 years
04
6 to 10 years
05
11 or more years
48. Staff #1: After the incident, was the staff
perpetrator – (Mark all that apply.)

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

No action taken

01
02
03
04
05
06
07
08
09
10
11

Page 6

FORM SSV-IA (04-10-2024)

➞ If there were no other staff perpetrators
involved, please skip to Notes on page 8
(if applicable) or submit form.
49. Staff #2: What was the staff perpetrator’s
gender?
01

Male

Female

50. Staff #2: What was the staff perpetrator’s age
at the time of the incident?
years
51. Staff #2: What was the staff perpetrator’s race
or ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

52. Staff #2: Was the staff perpetrator involved in
the incident –
01
02
03
04

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

53. Staff #2: What was the primary position
description of the staff perpetrator involved in
the incident?
01
Correctional officer, supervisory or security staff, or
direct care staff
02
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
03
Medical or healthcare staff, including counselors,
doctors, dentists, psychologists, psychiatrists, social
workers, nurses, and medical assistants
Education staff, including instructors, teachers,
04
librarians, and education assistants
05
Member of the clergy or chaplaincy
06
Administrator, including wardens, superintendents,
assistants and others in administrative positions
07
Clerical staff including secretaries, clerks,
receptionists, and other administrative support
08
Other program staff
09
Volunteers or interns
10
Other staff – Specify

54. Staff #2: At the time of the incident, how long
had the staff perpetrator worked at the
facility?
01
Less than 6 months
02
6 months to 1 year
03
1 to 5 years
04
6 to 10 years
05
11 or more years
55. Staff #2: After the incident, was the staff
perpetrator – (Mark all that apply.)

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

No action taken

01
02
03
04

05
06
07
08
09
10
11

FORM SSV-IA (04-10-2024)

Page 7

NOTES

Page 8

FORM SSV-IA (04-10-2024)

DEFINITIONS
Sexual victimization
Inmate-on-inmate sexual abuse: Sexual abuse of an inmate, detainee, or resident by another inmate, detainee, or resident
includes any of the following acts, if the victim does not consent, is coerced into such act by overt or implied threats of violence, or
is unable to consent or refuse:
1) Contact between the penis and the vulva or the penis and the anus, including penetration, however slight;
2) Contact between the mouth and the penis, vulva, or anus;
3) Penetration of the anal or genital opening of another person, however slight, by a hand, finger, object, or other instrument; and
4) Any other intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or the
buttocks of another person, excluding contact incidental to a physical altercation.
Inmate-on-inmate sexual harassment: 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, detainee, or resident directed toward
another.
Staff-on-inmate sexual abuse: Sexual abuse of an inmate, detainee, or resident by a staff member, contractor, or volunteer
includes any of the following acts, with or without consent of the inmate, detainee, or resident:
1) Contact between the penis and the vulva or the penis and the anus, including penetration, however slight;
2) Contact between the mouth and the penis, vulva, or anus;
3) Contact between the mouth and any body part where the staff member, contractor, or volunteer has the intent to abuse, arouse, or
gratify sexual desire;
4) Penetration of the anal or genital opening, however slight, by a hand, finger, object, or other instrument, that is unrelated to official
duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or gratify sexual desire;
5) Any other intentional contact, either directly or through the clothing, of or with the genitalia, anus, groin, breast, inner thigh, or the
buttocks, that is unrelated to official duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or
gratify sexual desire;
6) Any attempt, threat, or request by a staff member, contractor, or volunteer to engage in the activities described in paragraphs
(1) - (5) of this section;
7) Any display by a staff member, contractor, or volunteer of his or her uncovered genitalia, buttocks, or breast in the presence of an
inmate, detainee, or resident, and
8) Voyeurism by a staff member, contractor, or volunteer.
Staff-on-inmate sexual harassment: Repeated verbal comments or gestures of a sexual nature to an inmate, detainee, or
resident by a staff member, contractor, or volunteer, including demeaning references to gender, sexually suggestive or derogatory
comments about body or clothing, or obscene language or gestures.
Sex and gender identity
Sex: A multidimensional construct based on a cluster of anatomical and physiological traits that include external genitalia,
secondary sex characteristics, gonads, chromosomes, and hormones.
Gender identity: A person’s core internal understanding or sense of who they are regardless of sex assigned 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 differences in sex development (DSD).
Gender nonconforming: A person whose appearance or manner does not conform to traditional societal gender expectations.
Transgender: A person whose gender identity is different from the person’s sex assigned at birth.
Disability
Disability: A (1) physical or mental impairment that substantially limits one or more of the major life activities of [an] individual;
(2) a record of such an impairment; or (3) being regarded as having such an impairment.

FORM SSV-IA (04-10-2024)

Page 9

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

SSV-IJ

U.S. DEPARTMENT OF JUSTICE

FORM
(04-10-2024)

SURVEY OF SEXUAL VICTIMIZATION, 2023

BUREAU OF JUSTICE STATISTICS
and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

Substantiated Incident Form (Juvenile)

U.S. CENSUS BUREAU

Incident Number ___ out of ___
1. Did the incident include repeated behaviors?
01

Yes

4. Did the incident take place in an area subject
to video monitoring? (Mark all that apply.)

If "Yes" ➔ a. On approximately, how many
different dates did it occur? . . .

01
02

➔ b. On what date did the most

If "No" ➔ a. On what date did the incident
occur?
Month
Day
Year

2. In what facility did the incident occur?
Name
State

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

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

03
04
05
06
07
08

In a recreation area (e.g., yard, courtyard, gymnasium)

09
10

In a medical area (e.g., infirmary, health clinic)
In a staff area (e.g., office, break room, counselor’s office)

Offsite or while in transit

Other – Specify

Location unknown
Location not applicable (e.g., involved written, phone,
or virtual communication)

Unknown

recent incident occur?
Month
Day
Year

City

Yes
No

6. Who reported the incident?
(Mark all that apply.)
01
Victim
02
Another youth (non-victim)
03
Victim’s family, friend, or legal guardian
04
Correctional officer or front-line staff
05
Administrative staff
06
Medical, healthcare, or mental health staff
07
Instructor, teacher, or counselor
08
Other staff (e.g., kitchen worker, maintenance staff)
09
Chaplain or other religion official
10
Perpetrator
11
Perpetrator’s family, friend, or legal guardian
12
Grievance coordinator, grievance process, or ombuds
13
Attorney (victim’s or perpetrator’s)
14
Confidential informant, anonymous tip, hotline, or
through monitoring (e.g., camera, telephone, or mail)
15
Other – Specify

7. What was the type of sexual victimization incident?
(See definitions on page 9.)
01
Youth-on-youth sexual abuse
➞ Complete sections A and B
02
Youth-on-youth sexual harassment
➞ Complete sections A and B
03
Staff-on-youth sexual abuse
➞ Complete sections A and C
04
Staff-on-youth sexual harassment
➞ Complete sections A and C

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 30 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.

Female

10. Victim #1: What was the victim’s gender
identity?
Gender identity is a person’s core internal understanding
or sense of who they are regardless of sex assigned at
birth.
01
Male
02
03
04

15. Victim #1: Did the victim sustain any physical
injury during the incident?
01
Yes 02
No 03
Unknown
If "Yes" ➔ a. What injuries occurred?
(Mark all that apply.)

Female
Transgender [A person whose gender identity is
different from the person’s sex assigned at birth.]

01
02
03

Gender nonconforming [A person whose gender
identity does not conform to traditional societal
gender expectations.]

04
05
06

05
06

Other – Specify
Unknown

07
08
09
10

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

➔ b. Did the victim receive medical

treatment for these injuries?
Yes 02
No 03
Unknown

12. Victim #1: What was the victim’s race or
ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

16. Victim #1: After the incident was reported,
was the victim – (Mark all that apply.)
01
02
03
04
05
06
07

13. Victim #1: What was the victim’s citizenship?
01
02
03

Page 2

A U.S. citizen
Not a U.S. citizen
Of unknown citizenship status

08
09

FORM SSV-IJ (04-10-2024)

Section A – VICTIMS OF SEXUAL VICTIMIZATION
17. Victim #1: After the incident was reported,
was the victim – (Mark all that apply.)

None of the above

01
02
03
04
05
06
07
08
09

➔ If there were no other victims, please skip

to Section B on pages 4-5 if the incident
involved a youth perpetrator or Section C on
pages 6-7 if the incident involved a staff
perpetrator.

22. Victim #2: What was the victim’s citizenship?
01
02
03

23. Victim #2: Was the victim identiﬁed as having
any of the following disabilities at the time
of the incident? (Mark all that apply.)
01

Male

Female

Male

Female

Transgender

Gender nonconforming

Intersex

03
05

06
07

Other – Specify

08
09

Unknown

21. Victim #2: What was the victim’s race or
ethnicity? (Mark all that apply.)

05
06
07
08

Unknown

treatment for these injuries?
Yes 02
No 03
Unknown

25. Victim #2: After the incident was reported,
was the victim – (Mark all that apply.)
01
02
03
04
05
06
07
08
09

FORM SSV-IJ (04-10-2024)

➔ b. Did the victim receive medical

years

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

Yes

A physical impairment or disability (e.g., back or spinal
injury, blindness or low vision, deafness or hearing loss,
diabetes, epilepsy, heart disease, mobility impairments,
etc.)

If "Yes" ➔ a. What injuries occurred?
(Mark all that apply.)

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

24. Victim #2: Did the victim sustain any physical
injury during the incident?

18. Victim #2: What was the victim’s sex assigned
at birth?
01

A U.S. citizen
Not a U.S. citizen
Of unknown citizenship status

Page 3

26. Victim #2: After the incident was reported,
was the victim – (Mark all that apply.)
Separated from perpetrator
Confined to own cell or room
Placed in or returned to restrictive housing

01
02
03

Placed in a medical unit, ward, or hospital
Placed in camera room, under close surveillance,
or increased supervision
Transferred to another housing unit or dorm, or
given a single room or cell
Given a higher custody level or different unit within
the facility
Transferred to another facility
Issued disciplinary report or loss of privileges
Other – Specify

None of the above

04
05
06
07
08
09

28. What types of pressure, coercion, or force
occurred as part of the incident?
(Mark all that apply.)
01
02
03
04
05
06
07

Persuasion or talked into sexual activity
Bribery or blackmail
Gave the victim drugs or alcohol
Offered protection from other youth
Threats made (e.g., threatened harm to victim or
victim’s family, threatened with a weapon)
Unwanted touching, grabbing, or groping of the victim by
surprise or while the victim was asleep or incapacitated
Physically held victim down or restrained in some way,
including having other youth restrain the victim

Physical harm or injury

Other – Specify

None of the above

29. How many youth perpetrators were involved
in the incident?
Section B – YOUTH PERPETRATORS OF
SEXUAL VICTIMIZATION
➔ If the perpetrator was a staff member, go to

Number of youth perpetrators . . . .
➞ If more than two youth perpetrators were
involved, please complete this form online.

Section C on pages 6-7.

27. What was the nature of the incident?
(Mark all that apply.)
01
02
03
04

05
06
07

30. Perpetrator #1: What was the youth perpetrator’s
sex assigned at birth?
Sex is a multidimensional construct based on a cluster of
anatomical and physiological traits that include external
genitalia, secondary sex characteristics, gonads,
chromosomes, and hormones.
01
Male
02

Female

31. Perpetrator #1: What was the youth perpetrator’s
gender identity?
Gender identity is a person’s core internal understanding
or sense of who they are regardless of sex assigned at
birth.
01

Male

Female
Transgender [A person whose gender identity is
different from the person’s sex assigned at birth.]

03
04

Gender nonconforming [A person whose gender
identity does not conform to traditional societal
gender expectations.]

Other – Specify
Unknown

Page 4

FORM SSV-IJ (04-10-2024)

32. Perpetrator #1: What was the youth
perpetrator’s age at the time of the incident?
years
33. Perpetrator #1: What was the youth
perpetrator’s race or ethnicity?
(Mark all that apply.)
01
02
03
04
05
06
07
08

36. Perpetrator #2: What was the youth
perpetrator’s gender identity?
(See definitions on page 9.)
01

Male

Female

Transgender

Gender nonconforming

02
03
04
05
06
07

Other – Specify

08
09
10
11
12
13

04
05
06
07
08

01
02
03
04
05
06
07

14
15

Other – Specify

10
11
12
13

35. Perpetrator #2: What was the youth
perpetrator’s sex assigned at birth?
01

Male

Female

FORM SSV-IJ (04-10-2024)

Confined to own cell or room
Placed in or returned to restrictive housing
Placed in higher custody level, restricted unit or
program, within the same facility
Transferred to other unit/cell or separated from victim
Transferred to another facility
Sent to counseling or mental health treatment
Given medical treatment or testing
(e.g., post-exposure prophylaxis (PEP), HIV/AIDS)
Loss of "good/gain" time, increase in "bad" time or
delayed release
Given extra work
Loss of privileges, disciplinary report or conduct
violation, or other reprimand
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, given new sentence, or fined
Awaiting a legal outcome

skip to Notes on page 8 (if applicable) or
submit form.

39. Perpetrator #2: After the incident, was the youth
perpetrator – (Mark all that apply.)

➔ If there were no other perpetrators, please

Unknown

38. Perpetrator #2: What was the youth
perpetrator’s race or ethnicity?
(Mark all that apply.)

years

Other – Specify

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

34. Perpetrator #1: After the incident, was the
youth perpetrator – (Mark all that apply.)

Intersex

Page 5

Section C – STAFF PERPETRATORS OF
SEXUAL VICTIMIZATION
➔ If the perpetrator was a youth, go to

Section B on pages 4-5.

45. Staff #1: Was the staff perpetrator involved in
the incident –
01
02
03

40. What was the nature of the incident?
(Mark all that apply.)
01
02
03

04
05
06
07
08
09

Repeated suggestive, derogatory, or obscene verbal
comments or gestures of a sexual nature
Wrote letters, showed pictures, talked on the phone, or
through video conferencing
Exhibited grooming or manipulative behaviors such
as providing gifts, special privileges, or favors to
youth
Indecent exposure, invasion of privacy, or voyeurism
Any attempt, threat, or request related to abusive
sexual contact or sexual acts
Any touching or kissing for sexual gratification
Pressure or abuse of power resulting in a sexual act
Physical force resulting in a sexual act
Other – Specify

46. Staff #1: What was the primary position
description of the staff perpetrator involved in
the incident?
01
02

04
05

09
10

Other staff – Specify

Number of staff . . . .

41. How many staff perpetrators were involved in
the incident?

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

➞ If more than two staff were involved, report
please complete this form online.
42. Staff #1: What was the staff perpetrator’s
gender?
01

Male

Female

No action taken

01
02
03
04
05
06
07
08
09
10
11

Page 6

FORM SSV-IJ (04-10-2024)

➞ If there were no other staff perpetrators
involved, please skip to Notes on page 8
(if applicable) or submit form.
49. Staff #2: What was the staff perpetrator’s
gender?
01

Male

Female

50. Staff #2: What was the staff perpetrator’s age
at the time of the incident?
years
51. Staff #2: What was the race/ethnic origin of the
staff perpetrator involved in the incident?
(Mark all that apply.)
01
02
03
04
05
06
07
08

52. Staff #2: Was the staff perpetrator involved in
the incident –
01
02
03
04

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

No action taken

01
02
03
04

05
06
07
08
09
10
11

FORM SSV-IJ (04-10-2024)

Page 7

NOTES

Page 8

FORM SSV-IJ (04-10-2024)

Deﬁnitions
Sexual victimization
Youth-on-youth sexual abuse: Sexual abuse of a youth, detainee, or resident by another youth, detainee, or resident
includes any of the following acts, if the victim does not consent, is coerced into such act by overt or implied threats of violence, or
is unable to consent or refuse:
1) Contact between the penis and the vulva or the penis and the anus, including penetration, however slight;
2) Contact between the mouth and the penis, vulva, or anus;
3) Penetration of the anal or genital opening of another person, however slight, by a hand, finger, object, or other instrument; and
4) Any other intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or the
buttocks of another person, excluding contact incidental to a physical altercation.
Youth-on-youth sexual harassment: 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, detainee, or resident directed toward
another.
Staff-on-youth sexual abuse: Sexual abuse of a youth, detainee, or resident by a staff member, contractor, or volunteer
includes any of the following acts, with or without consent of the youth, detainee, or resident:
1) Contact between the penis and the vulva or the penis and the anus, including penetration, however slight;
2) Contact between the mouth and the penis, vulva, or anus;
3) Contact between the mouth and any body part where the staff member, contractor, or volunteer has the intent to abuse, arouse, or
gratify sexual desire;
4) Penetration of the anal or genital opening, however slight, by a hand, finger, object, or other instrument, that is unrelated to official
duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or gratify sexual desire;
5) Any other intentional contact, either directly or through the clothing, of or with the genitalia, anus, groin, breast, inner thigh, or the
buttocks, that is unrelated to official duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or
gratify sexual desire;
6) Any attempt, threat, or request by a staff member, contractor, or volunteer to engage in the activities described in paragraphs
(1) - (5) of this section;
7) Any display by a staff member, contractor, or volunteer of his or her uncovered genitalia, buttocks, or breast in the presence of a
youth, detainee, or resident, and
8) Voyeurism by a staff member, contractor, or volunteer.
Staff-on-youth sexual harassment: Repeated verbal comments or gestures of a sexual nature to a youth, detainee, or
resident by a staff member, contractor, or volunteer, including demeaning references to gender, sexually suggestive or derogatory
comments about body or clothing, or obscene language or gestures.
Sex and gender identity
Sex: A multidimensional construct based on a cluster of anatomical and physiological traits that include external genitalia,
secondary sex characteristics, gonads, chromosomes, and hormones.
Gender identity: A person’s core internal understanding or sense of who they are regardless of sex assigned 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 differences in sex development (DSD).
Gender nonconforming: A person whose appearance or manner does not conform to traditional societal gender expectations.
Transgender: A person whose gender identity is different from the person’s sex assigned at birth.
Disability
Disability: A (1) physical or mental impairment that substantially limits one or more of the major life activities of [an] individual;
(2) a record of such an impairment; or (3) being regarded as having such an impairment.

FORM SSV-IJ (04-10-2024)

Page 9

File Type	application/pdf
Author	OneFormUser
File Modified	2024-04-22
File Created	2024-04-22