SSV IA SSV Incident Form Adult

Survey on Sexual Violence

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Survey on Sexual Violence

OMB: 1121-0292

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SSV-IA

U.S. DEPARTMENT OF JUSTICE

FORM
(3-24-2010)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VIOLENCE, 2009

and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

– Incident Form (Adult)

Economics and Statistics Admin.

U.S. CENSUS BUREAU

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

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

01
02
03
04

2. In what facility did the incident occur?
Name

01
02
03
04

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

02
03
04
05
06
07
08
09

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

05
06
07

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

03
04

35 – 39
40 – 44
45 or older

) all that

03
04

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

Male

Female

Under age 18
18 – 24
25 – 29
30 – 34

05
06
07

35 – 39
40 – 44
45 or older

11. Victim #2: What was the victim’s race/ethnic origin?
(Mark ( X ) all that apply.)
01

5. How many victims were involved in the incident?

02
03
04

Number of victims . . .

➔

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

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

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

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

City/Place

Under age 18
18 – 24
25 – 29
30 – 34

If no victims (only perpetrators) were
involved, report "0" above, and go to item 13.
➔ If more than two victims were reported,
report these characteristics in Notes.

06
07

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

Male

Female

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

12. Did the victim(s) sustain any physical injury
during the incident?
Yes ➔ a. What injuries occurred?
01
(Mark ( x ) all that apply for all victims.)
01
02
03
04
05
06
07
08

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

b. Did the victim(s) receive medical
treatment for these injuries?
Yes
No
No (No injury sustained)
01

13. Who reported the incident?
(Mark ( x ) all that apply.)
01
Victim
Another inmate (non-victim)
02
Family of victim
03
Correctional officer/front line staff
04
Administrative staff
05
Medical/healthcare staff
06
Instructor/teacher
07
Counselor
08
Chaplain or other religious official
09
Other – Specify
10

14. After the incident was reported, was the
victim(s) – (Mark ( x ) all that apply for all victims.)
01
02
03
04
05
06
07

Given a medical examination
Administered a rape kit
Tested for HIV/AIDS
Tested for other sexually transmitted diseases
Provided with counseling or mental health
treatment
None of the above
No victim (voluntary sexual contact)

15. After the incident was reported, was the
victim(s) – (Mark ( x ) all that apply for all victims.)
01
Placed in administrative segregation/protective
custody
02
Placed in a medical unit, ward, or hospital
03
Confined to own cell/room
04
Given a higher custody level within the facility
05
Transferred to another facility
06
Other – Specify

16. What type of sexual violence was involved in
the incident? (See definitions below)
01
02
05
03
04

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

Definitions of Sexual Violence
Nonconsensual Sexual Acts: Contact of any person
without his or her consent, or of a person who is unable to
consent or refuse;
AND
Contact between the penis and the vagina or the penis
and the anus including penetration, however slight; OR
Contact between the mouth and the penis, vagina, or
anus;
OR
Penetration of the anal or genital opening of another person
by the hand, finger, or other object.
Abusive Sexual Contact: (less severe) Contact of any
person without his or her consent, or of a person who is
unable to consent or refuse;
AND
Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
of any person.
EXCLUDES
Incidents in which the intent of the sexual contact is to harm
or debilitate rather than to sexually exploit.
Staff Sexual Misconduct: Any behavior or act of a sexual
nature directed toward an inmate by an employee, volunteer,
contractor, official visitor, or other agency representative
(exclude inmate family, friends, or other visitors).
Sexual relationships of a romantic nature between staff
and inmates are included in this definition. Consensual or
nonconsensual sexual acts including: Intentional touching
of the genitalia, anus, groin, breast, inner thigh, or buttocks
with the intent to abuse, arouse, or gratify sexual desire;
OR
Completed, attempted, threatened, or requested sexual acts;
OR
Occurrences of indecent exposure, invasion of privacy, or
staff voyeurism for sexual gratification.
Staff Sexual Harassment: Repeated verbal statements or
comments of a sexual nature to an inmate by an employee,
volunteer, contractor, official visitor, or other agency
representative (exclude inmate family, friends, or other
visitors). Demeaning references to gender or derogatory
comments about body or clothing;
OR
Repeated profane or obscene language or gestures.
Section A – INMATE-ON-INMATE SEXUAL VIOLENCE
17. How many perpetrators were involved in the
incident?
Number of perpetrators . . . .

07
08

Page 2

None of the above
No victim (voluntary sexual contact)

➔ If more than two perpetrators were involved,
report these characteristics in Notes.
FORM SSV-IA (3-24-2010)

18. Perpetrator #1: What was the perpetrator’s
gender?
01

Male

Female

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

Under age 18
18–24
25–29

04
05
06

30–34
35–39
40–44

45 or older

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

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

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

Male

Female

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

Under age 18
18–24
25–29

04
05
06

30–34
35–39
40–44

45 or older

25. What type of pressure or physical force was
used by the perpetrator on the victim?
(Mark ( x ) all that apply for all perpetrators.)
01
Persuasion or talked into sexual activity
02
Bribery or blackmail
Gave victim drugs or alcohol
03
Offered protection from other inmates
04
05
Threatened with physical harm
06
Physically held victim down or restrained in
some way
07
Physically harmed or injured
Threatened with a weapon
08
09
Other – Specify

10
11

None
No victim (voluntary sexual contact)

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

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

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

Section B – STAFF SEXUAL MISCONDUCT
AND HARASSMENT
27. What was the nature of the incident?
(Mark ( x ) all that apply.)

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

Level of coercion unknown

01
02
03
04
05

24. What was the nature of the incident?
(Mark ( x ) all that apply.)
01
02
03
04
05

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

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

FORM SSV-IA (3-24-2010)

Page 3

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

Male

Female

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

24 or younger
25 – 29
30 – 34
35 – 39

05
06
07

40 – 44
45 – 54
55 or older

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

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

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

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

Other staff – Specify

03
04

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

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

Other – Specify

01
02
03

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

Male

Female

04
05
06

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

24 or younger
25 – 29
30 – 34
35 – 39

05
06
07

40 – 44
45 – 54
55 or older

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

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

NOTES

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

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

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

FORM SSV-IA (3-24-2010)

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