SSVIJ form BJS markup

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

SSV-IJ

U.S. DEPARTMENT OF JUSTICE

FORM
(07-09-2024)

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

02

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

No

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)

02

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)

11

Off-site or while in transit

12

Other – Specify

13

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

14

03

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 youth (nonvictim)
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
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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.