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Questionnaires
OMB No. 1121-0292: Approval Expires 04/30/2018
U.S. DEPARTMENT OF JUSTICE
SSV-1
FORM
(5-17-2017)
BUREAU OF JUSTICE STATISTICS
SURVEY OF SEXUAL VICTIMIZATION, 2016
Federal Bureau of Prisons
Summary Form
AND ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
DATA SUPPLIED BY
TELEPHONE
E-MAIL
ADDRESS
City
Number and street or P.O. Box/Route Number
Area code
Number
FAX
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, 2016, and
December 31, 2016.
• 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," mark the
box ( X ) provided.
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 Greta Clark at the
U.S. Census Bureau toll–free at 1–800–253–2078, or
e-mail govs.ssv@census.gov
• Please return your completed summary
and substantiated incident forms by August 15,
2017.
• You may complete these forms online (see
enclosed instructions). Or if you prefer, you may
return these forms by mail or fax.
• 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
NONCONSENSUAL SEXUAL ACTS?
01
The survey utilizes the definition of “sexual abuse” as
provided by 28 C.F.R. §115.6 in the National Standards to
Prevent, Detect, and Respond to Prison Rape (under the
Prison Rape Elimination Act of 2003). For purposes of SSV,
sexual abuse is disaggregated into three categories of
inmate-on-inmate sexual victimization. These categories are:
Yes ➔ a. Do you record all reported
occurrences, or only substantiated
ones?
01
All
02
Substantiated only
b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS
or only completed ones?
NONCONSENSUAL SEXUAL ACTS
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
AND
02
No
01
Both attempted and completed
02
Completed only
➔ Please provide the definition used by the
Federal Bureau of Prisons for
inmate-on-inmate NONCONSENSUAL
SEXUAL ACTS in the space below. Use that
definition to complete Items 2 and 3.
• Contact between the penis and the vulva or the penis
and the anus including penetration, however slight;
OR
• Contact between the mouth and the penis, vulva, or
anus;
OR
• Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument.
2. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS were reported?
ABUSIVE SEXUAL CONTACT
Number reported . . . . . .
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
• If an allegation involved multiple victimizations,
count only once.
• Exclude any allegations that were reported as
consensual.
AND
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks of any person.
• EXCLUDE incidents in which the contact was incidental
to a physical altercation.
None
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 . . . . . . .
SEXUAL HARASSMENT
None
• The event was investigated and determined to
have occurred, based on a preponderance of the
evidence (28 C.F.R. §115.72).
Repeated and unwanted sexual advances, requests for
sexual favors, or verbal comments, gestures, or actions
of a derogatory or offensive sexual nature by one inmate
directed toward another.
b. Unsubstantiated . . . . .
None
• The investigation concluded that evidence was
insufficient to determine whether or not the event
occurred.
c. Unfounded . . . . . . . . . .
None
• The investigation determined that the event did NOT
occur.
d. Investigation ongoing .
None
• 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) . . . . . . . . .
None
• The total should equal the number reported in Item 2.
FORM SSV-1 (5-17-2017)
Page 2
7. Does the Federal Bureau of Prisons record
allegations of inmate-on-inmate SEXUAL
HARASSMENT? (See definitions on page 2.)
4. Does the Federal Bureau of Prisons record
allegations of inmate-on-inmate ABUSIVE
SEXUAL CONTACT? (See definitions on page 2.)
01
Yes
➔ Can these be counted separately from
01
allegations of NONCONSENSUAL
SEXUAL ACTS?
01
02
02
No
Yes
Yes
No ➔ Skip to Item 7.
➔ Please provide an explanation in the space
02
below and then skip to Item 7.
.....
allegations or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Section II.
5. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
ABUSIVE SEXUAL CONTACT were reported?
Number reported
No
➔ Do you record all reported
8. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
SEXUAL HARASSMENT were reported?
Number reported . . . . . .
None
None
• If an allegation involved multiple victimizations,
count only once.
• If an allegation involved multiple victims or
inmate perpetrators, count only once.
• Exclude any allegations that were reported as
consensual.
• Exclude any allegations that were reported as
consensual.
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.)
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.)
a. Substantiated . . . . . . .
None
a. Substantiated
b. Unsubstantiated . . . . .
None
b. Unsubstantiated
.....
None
c. Unfounded
None
c. Unfounded . . . . . . . . . .
None
d. Investigation ongoing
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
6a through 6d) . . . . . . . . .
None
e. TOTAL (Sum of Items
9a through 9d) . . . . . . . . .
None
.........
None
• The total should equal the number reported in
Item 8.
• The total should equal the number reported in
Item 5.
FORM SSV-1 (5-17-2017)
.......
Page 3
SECTION II – STAFF-ON-INMATE SEXUAL ABUSE
DEFINITIONS
10. Does the Federal Bureau of Prisons
record allegations of STAFF SEXUAL
MISCONDUCT?
The survey utilizes the definition of “sexual abuse” by a staff
member, contractor or volunteer as provided by 28 C.F.R.
§115.6 in the National Standards to Prevent, Detect, and
Respond to Prison Rape (under the Prison Rape Elimination
Act of 2003). For purposes of SSV, sexual abuse is
disaggregated into two categories of staff-on-inmate sexual
abuse. These categories are:
01
STAFF SEXUAL MISCONDUCT
02
Yes
No
➔ Do you record all reported
occurrences, or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Item 13.
Any behavior or act of a sexual nature directed toward an
inmate by an employee, volunteer, contractor, official visitor or
other agency representative (exclude family, friends or other
visitors).
Sexual relationships of a romantic nature between staff and
inmates are included in this definition. Consensual or
nonconsensual sexual acts include—
• Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
that is unrelated to official duties or with the intent to abuse,
arouse, or gratify sexual desire;
OR
• Completed, attempted, threatened, or requested sexual acts;
11. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
OR
Number reported
• Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reasons unrelated to official duties
or for sexual gratification.
......
None
• If an allegation involved multiple victimizations,
count only once.
STAFF SEXUAL HARASSMENT
Repeated verbal statements, comments or gestures of a sexual
nature to an inmate by an employee, volunteer, contractor,
official visitor, or other agency representative (exclude family,
friends, or other visitors). Include—
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.)
• Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;
OR
• Repeated profane or obscene language or gestures.
a. Substantiated . . . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded
.........
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
12a through 12d) . . . . . . .
None
• The total should equal the number reported in
Item 11.
FORM SSV-1 (5-17-2017)
Page 4
Section III – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
13. Does the Federal Bureau of Prisons record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 4.)
01
Yes
➔ Can these allegations be counted
16. What is the total number of substantiated
incidents reported Items 3a, 6a, 9a, 12a, and 15a?
separately from allegations of STAFF
SEXUAL MISCONDUCT?
02
No
01
Yes
02
No
➔ Skip to Item 16.
Total substantiated
incidents . . . . . . . . . . . . .
➔
➔ Please provide an explanation in the space
Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.
below and then skip to Item 16.
NOTES
14. Between January 1, 2016, and
December 31, 2016, how many allegations
of STAFF SEXUAL HARASSMENT were
reported?
Number reported
......
None
• If an allegation involved multiple victims or staff,
count only once.
15. Of the allegations reported in Item 14, 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 . . . . . . .
None
b. Unsubstantiated
....
None
.........
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
15a through 15d) . . . . . . .
None
c. Unfounded
• The total should equal the number reported in
Item 14.
FORM SSV-1 (5-17-2017)
Page 5
None
OMB No. 1121-0292: Approval Expires 04/30/2018
U.S. DEPARTMENT OF JUSTICE
SSV-2
FORM
(5-17-2017)
BUREAU OF JUSTICE STATISTICS
SURVEY OF SEXUAL VICTIMIZATION, 2016
State Prison Systems
Summary Form
AND ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
DATA SUPPLIED BY
TELEPHONE
E-MAIL
ADDRESS
City
Number and street or P.O. Box/Route Number
Area code
Number
FAX
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, 2016, and
December 31, 2016.
• 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," mark the
box ( X ) provided.
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 Greta Clark at the
U.S. Census Bureau toll–free at 1–800–253–2078, or
e-mail govs.ssv@census.gov
• Please return your completed summary and
substantiated incident forms by August 15,
2017.
• You may complete these forms online (see
enclosed instructions.) Or if you prefer, you may
return these forms by mail or fax.
• 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
NONCONSENSUAL SEXUAL ACTS?
DEFINITIONS
Yes ➔ a. Do you record all reported
01
occurrences, or only substantiated
The survey utilizes the definition of “sexual abuse” as
ones?
provided by 28 C.F.R. §115.6 in the National Standards to
Prevent, Detect, and Respond to Prison Rape (under the
01
All
Prison Rape Elimination Act of 2003). For purposes of SSV,
sexual abuse is disaggregated into three categories of
02
Substantiated only
inmate-on-inmate sexual victimization. These categories are:
b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS
or only completed ones?
NONCONSENSUAL SEXUAL ACTS
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
AND
• Contact between the penis and the vulva or the penis
and the anus including penetration, however slight;
02
No
01
Both attempted and completed
02
Completed only
➔ Please provide the definition used by your
State prison system for inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS in the
space below. Use that definition to complete
Items 2 and 3.
OR
• Contact between the mouth and the penis, vulva, or
anus;
OR
• Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument.
ABUSIVE SEXUAL CONTACT
2. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS were reported?
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
Number reported . . . . . .
None
• If an allegation involved multiple victimizations,
count only once.
AND
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks of any person.
• EXCLUDE incidents in which the contact was incidental
to a physical altercation.
• 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.)
SEXUAL HARASSMENT
Repeated and unwanted sexual advances, requests for
sexual favors, or verbal comments, gestures, or actions
of a derogatory or offensive sexual nature by one inmate
directed toward another.
a. Substantiated
None
......
• The event was investigated and determined to
have occurred, based on a preponderance of the
evidence (28 C.F.R. §115.72).
b. Unsubstantiated
None
....
• The investigation concluded that evidence was
insufficient to determine whether or not the event
occurred.
None
c. Unfounded . . . . . . . . .
• The investigation determined that the event did NOT
occur.
d. Investigation ongoing
.
None
• 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) . . . . . . . .
None
• The total should equal the number reported in Item 2.
FORM SSV-2 (5-17-2017)
Page 2
7. Does your State prison system record
allegations of inmate-on-inmate SEXUAL
HARASSMENT? (See definitions on page 2.)
4. Does your State prison system record
allegations of inmate-on-inmate ABUSIVE
SEXUAL CONTACT? (See definitions on page 2.)
01
Yes
➔ Can these be counted separately from
01
Yes
allegations of NONCONSENSUAL
SEXUAL ACTS?
01
02
02
No
Yes
No ➔ Skip to Item 7.
➔ Please provide an explanation in the space
02
below and then skip to Item 7.
No
➔ Do you record all reported
allegations or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Section II.
5. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
ABUSIVE SEXUAL CONTACT were reported?
8. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
SEXUAL HARASSMENT were reported?
Number reported . . . . . .
None
• If an allegation involved multiple victimizations,
count only once.
Number reported . . . . . .
• If an allegation involved multiple victims or
inmate perpetrators, count only once.
• Exclude any allegations that were reported as
consensual.
• Exclude any allegations that were reported as
consensual.
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.)
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.)
None
None
a. Substantiated . . . . . . .
None
a. Substantiated
b. Unsubstantiated . . . . .
None
b. Unsubstantiated
....
None
c. Unfounded
.........
None
c. Unfounded . . . . . . . . .
None
d. Investigation ongoing .
None
d. Investigation ongoing
e. TOTAL (Sum of Items
6a through 6d) . . . . . . . . .
None
e. TOTAL (Sum of Items
9a through 9d) . . . . . . . .
.
None
None
• The total should equal the number reported in
Item 8.
• The total should equal the number reported in
Item 5.
FORM SSV-2 (5-17-2017)
......
Page 3
SECTION II – STAFF-ON-INMATE SEXUAL ABUSE 10. Does your State prison system record
allegations of STAFF SEXUAL
MISCONDUCT?
DEFINITIONS
The survey utilizes the definition of “sexual abuse” by a staff
member, contractor or volunteer as provided by 28 C.F.R.
§115.6 in the National Standards to Prevent, Detect, and
Respond to Prison Rape (under the Prison Rape Elimination
Act of 2003). For purposes of SSV, sexual abuse is
disaggregated into two categories of staff-on-inmate sexual
abuse. These categories are:
01
STAFF SEXUAL MISCONDUCT
02
Yes
No
➔ Do you record all reported
occurrences, or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Item 13.
Any behavior or act of sexual nature directed toward an inmate
by an employee, volunteer, contractor, official visitor or other
agency representative (exclude family, friends or other visitors).
Sexual relationships of a romantic nature between staff and
inmates are included in this definition. Consensual or
nonconsensual sexual acts include—
• Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
that is unrelated to official duties or with the intent to abuse,
arouse, or gratify sexual desire;
OR
• Completed, attempted, threatened, or requested sexual acts;
11. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
Number reported . . . . . . .
None
• If an allegation involved multiple victimizations,
count only once.
OR
• Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reasons unrelated to official duties
or for sexual gratification.
STAFF SEXUAL HARASSMENT
Repeated verbal statements, comments or gestures of a sexual
nature to an inmate by an employee, volunteer, contractor,
official visitor, or other agency representative (exclude family,
friends, or other visitors). Include—
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 . . . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded . . . . . . . . . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
12a through 12d) . . . . . . .
None
• Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;
OR
• Repeated profane or obscene language or gestures.
• The total should equal the number reported in
Item 11.
FORM SSV-2 (5-17-2017)
Page 4
13. 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
separately from allegations of STAFF
SEXUAL MISCONDUCT?
02
No
01
Yes
02
No
➔ Skip to Item 16.
➔ Please provide an explanation in the space
16. Did any of the allegations reported in Items 2,
5, 8, 11, or 14 occur in a privately operated
facility?
01
Yes
02
No
17. Did any of the allegations reported in Items 2,
5, 8, 11, or 14 occur in a facility operated and
administered by local governments?
below and then skip to Item 16.
01
Yes
02
No
Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
18. What is the total number of substantiated
incidents reported in Items 3a, 6a, 9a, 12a, and
15a?
Total substantiated
incidents . . . . . . . . . . . .
14. Between January 1, 2016, and
December 31, 2016, how many allegations
of STAFF SEXUAL HARASSMENT were
reported?
➔
15. Of the allegations reported in Item 14, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)
......
None
b. Unsubstantiated . . . .
None
c. Unfounded . . . . . . . . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
15a through 15d) . . . . . .
None
a. Substantiated
• The total should equal the number reported in
Item 14.
FORM SSV-2 (5-17-2017)
Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.
NOTES
Number reported . . . . . .
None
• If an allegation involved multiple victims or staff,
count only once.
Page 5
None
OMB No. 1121-0292: Approval Expires 04/30/2018
U.S. DEPARTMENT OF JUSTICE
SSV-3
FORM
(4-26-2017)
SURVEY OF SEXUAL VICTIMIZATION, 2016
Local Jail Jurisdictions
Summary Form
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
DATA SUPPLIED BY
TELEPHONE
E-MAIL
ADDRESS
City
Number and street or P.O. Box/Route Number
Area code
Number
FAX
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 usually operated by a local law
enforcement agency that are intended for adults but
sometimes hold juveniles.
• 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, 2016, and
December 31, 2016.
• 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-3 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" or mark the box ( X )
provided.
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 Greta Clark at the
U.S. Census Bureau toll–free at 1–888–369–3613,
option 2, or e-mail govs.ssv@census.gov
• Please return your completed summary
and substantiated incident forms by
August 1, 2017.
• You may complete these forms online (see
enclosed instructions). Or if you prefer, you may
return these forms by mail or fax.
• 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
The survey utilizes the definition of “sexual abuse” as
provided by 28 C.F.R. §115.6 in the National Standards
to Prevent, Detect, and Respond to Prison Rape (under
the Prison Rape Elimination Act of 2003). For purposes
of SSV, sexual abuse is disaggregated into three
categories of inmate-on-inmate sexual victimization.
These categories are:
a. CONFINED in your jail facilities on
December 31, 2016?
• INCLUDE persons on transfer to treatment facilities
but who remain under your jurisdiction.
• INCLUDE persons out to court while under your
jurisdiction.
NONCONSENSUAL SEXUAL ACTS
• INCLUDE persons held for other jurisdictions.
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
• EXCLUDE persons housed in facilities operated by
two or more jurisdictions or those held in
privately-operated jails.
AND
• EXCLUDE inmates on AWOL, escape, or long-term
transfer to other jurisdictions.
• 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 jail (e.g.,
electronic monitoring, house arrest, community
service, day reporting, work programs).
OR
• Contact between the mouth and the penis, vulva, or
anus;
OR
Male
Female
• Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or other
instrument.
Inmates on
December 31, 2016 . . .
ABUSIVE SEXUAL CONTACT
b. ADMITTED to your jail facilities during 2016?
• 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
AND
• Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or
buttocks of any person.
• EXCLUDE incidents in which the contact was incidental
to a physical altercation.
SEXUAL HARASSMENT
Female
Repeated and unwelcome sexual advances, requests
for sexual favors, or verbal comments, gestures, or
actions of a derogatory or offensive sexual nature by
one inmate directed toward another.
New admissions
during 2016 . . . . . . . . .
2. Between January 1, 2016, and
December 31, 2016, 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, 2016, through December 31, 2016, and
divide the result by 365.
Male
Female
Average daily
population . . . . . . . . . . .
FORM SSV-3 (4-26-2017)
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
Page 2
3. Does your local jail jurisdiction record allegations
of inmate-on-inmate NONCONSENSUAL SEXUAL
ACTS? (See definitions on page 2.)
Yes ➔ a. Do you record all reported
01
occurrences, or only substantiated
ones?
6. Does your local jail jurisdiction record
allegations of inmate-on-inmate ABUSIVE
SEXUAL CONTACT? (See definitions on page 2.)
01
No
➔ Can these be counted separately from
allegations of NONCONSENSUAL
SEXUAL ACTS?
01
All
01
02
Substantiated only
02
b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS or
only completed ones?
02
Yes
01
Both attempted and completed
02
Completed only
02
No
➔
Yes
No ➔ Skip to Item 9.
Please provide an explanation in the space
below and then skip to Item 9.
➔ Please provide the definition used by your
local jail jurisdiction for inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS in the
space below. Use that definition to complete
Items 4 and 5.
4. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS were reported?
7. Between January 1, 2016, and December 31, 2016,
how many allegations of inmate-on-inmate
ABUSIVE SEXUAL CONTACT were reported?
Number reported . . . . . . .
None
• If an allegation involved multiple victimizations,
count only once.
• Exclude any allegations that were reported as
consensual.
Number reported . . . . .
None
If
an
allegation
involved
multiple
victimizations,
count only
•
once.
• 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.)
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
.......
None
• The event was investigated and determined to
have occurred, based on a preponderance of the
evidence (28 C.F.R. §115.72).
b. Unsubstantiated
.....
a. Substantiated . . . . . . . .
None
b. Unsubstantiated
.....
None
..........
None
None
c. Unfounded
• The investigation concluded that evidence was
insufficient to determine whether or not the event
occurred.
d. Investigation ongoing
c. Unfounded . . . . . . . . . .
None
.
None
• 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) . . . . . . . . .
None
• The total should equal the number reported in Item 4.
FORM SSV-3 (4-26-2017)
None
e. TOTAL (Sum of Items
None
8a through 8d) . . . . . . . . . .
• The total should equal the number reported in
Item 7.
• The investigation determined that the event did
NOT occur.
d. Investigation ongoing
.
Page 3
Section III – STAFF-ON-INMATE SEXUAL ABUSE
9. Does your local jail jurisdiction record
allegations of inmate-on-inmate SEXUAL
HARASSMENT? (See definitions on page 2.)
01
02
Yes
No
DEFINITIONS
➔ Do you record all reported
The survey utilizes the definition of “sexual abuse” by a
staff member, contractor or volunteer as provided by
28 C.F.R. §115.6 in the National Standards to Prevent,
Detect, and Respond to Prison Rape (under the Prison
Rape Elimination Act of 2003). For purposes of SSV,
sexual abuse is disaggregated into two categories of
staff-on-inmate sexual abuse. These categories are:
allegations or only substantiated
ones?
➔
01
All
02
Substantiated only
Please provide an explanation in the space
below and then skip to Section III.
STAFF SEXUAL MISCONDUCT
Any behavior or act of a sexual nature directed toward an
inmate by an employee, volunteer, contractor, official
visitor or other agency representative (exclude family,
friends or other visitors).
Sexual relationships of a romantic nature between staff
and inmates are included in this definition. Consensual or
nonconsensual sexual acts include—
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner
thigh, or buttocks that is unrelated to official duties or
with the intent to abuse, arouse, or gratify sexual
desire;
10. Between January 1, 2016, and December 31,
2016, how many allegations of
inmate-on-inmate SEXUAL HARASSMENT were
reported?
None
Number reported . . . . . . .
• If an allegation involved multiple victims or
inmate perpetrators, count only once.
• Exclude any allegations that were reported as
consensual.
OR
• Completed, attempted, threatened, or requested
sexual acts;
OR
11. Of the allegations reported in Item 10, how many
were—
• Occurrences of indecent exposure, invasion of
privacy, or staff voyeurism for reasons unrelated to
official duties or for sexual gratification.
None
STAFF SEXUAL HARASSMENT
b. Unsubstantiated . . . . . .
None
Repeated verbal statements, comments or gestures of a
sexual nature to an inmate by an employee, volunteer,
contractor, official visitor, or other agency representative
(exclude family, friends, or other visitors). Include—
c. Unfounded
None
• Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;
a. Substantiated . . . . . . . .
..........
d. Investigation ongoing
.
OR
None
• Repeated profane or obscene language or gestures.
e. TOTAL (Sum of Items
None
11a through 11d) . . . . . . . .
• The total should equal the number reported in
Item 10.
FORM SSV-3 (4-26-2017)
Page 4
15. Does your local jail jurisdiction record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 4.)
12. Does your local jail jurisdiction record
allegations of STAFF SEXUAL MISCONDUCT?
(See definitions on page 4.)
01
02
Yes ➔ Do you record all reported
occurrences, or only substantiated
ones?
No
01
Yes ➔ Can these allegations be counted
separately from allegations of
STAFF SEXUAL MISCONDUCT?
01
All
01
Yes
02
Substantiated only
02
No ➔ Skip to Item 18.
➔ Please provide an explanation in the space
02
13. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
Number reported
.....
➔ Please provide an explanation in the space
16. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL HARASSMENT were reported?
Number reported
None
.....
None
• If an allegation involved multiple victims or staff,
count only once.
• If an allegation involved multiple victimizations, or
staff, count only once.
14. 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.)
No
below and then skip to Item 18.
below and then skip to Item 15.
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 . . . . . . . .
None
a. Substantiated . . . . . . .
None
b. Unsubstantiated . . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded
None
c. Unfounded
.........
None
None
d. Investigation ongoing .
None
None
e. TOTAL (Sum of Items 17a
through 17d) . . . . . . . . . .
None
..........
d. Investigation ongoing
.
e. TOTAL (Sum of Items
14a through 14d) . . . . . . . .
• The total should equal the number
reported in Item 13.
FORM SSV-3 (4-26-2017)
• The number should equal the number
reported in Item 16.
Page 5
Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
NOTES
18. What is the total number of substantiated
incidents reported in Items 5a, 8a, 11a,
14a, and 17a?
Total substantiated
incidents . . . . . . . . . . . .
➔
None
Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.
FORM SSV-3 (4-26-2017)
Clear Fields
Page 6
Print Form
Save As
OMB No. 1121-0292: Approval Expires 4/30/2018
U.S. DEPARTMENT OF JUSTICE
SSV-4
FORM
(4-26-2017)
BUREAU OF JUSTICE STATISTICS
SURVEY OF SEXUAL VICTIMIZATION, 2016
Other Correctional Facilities
Summary Form
AND ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
DATA SUPPLIED BY
TELEPHONE
E-MAIL
ADDRESS
City
Number and street or P.O. Box/Route Number
Area code
Number
FAX
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?
• 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
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" or mark the box ( X ) provided.
Substantiated incidents of sexual violence:
• Please complete an Incident Form (Adult, SSV-IA)
for each substantiated incident of sexual victimization.
• TRIBAL AUTHORITIES
• THE BUREAU OF INDIAN AFFAIRS
What inmates and incidents are included in this data
collection?
Inmates under your custody between January 1, 2016, and
December 31, 2016.
• 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.
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 govs.ssv@census.gov
• Please return your completed summary and
substantiated incident forms by
August 1, 2017.
• You may complete these forms online (see
enclosed instructions). Or if you prefer, you may
return these forms by mail or fax.
• 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
• INCLUDE persons on transfer to treatment
facilities but who remain under your
jurisdiction.
The survey utilizes the definition of “sexual abuse” as
provided by 28 C.F.R. §115.6 in the National Standards to
Prevent, Detect, and Respond to Prison Rape (under the
Prison Rape Elimination Act of 2003). For purposes of SSV,
sexual abuse is disaggregated into three categories of
inmate-on-inmate sexual victimization. These categories are:
• INCLUDE persons out to court while under your
jurisdiction.
NONCONSENSUAL SEXUAL ACTS
a. CONFINED on December 31, 2016?
• INCLUDE persons held for other jurisdictions.
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
• EXCLUDE inmates on AWOL, escape, or
long-term transfer to other jurisdictions.
AND
• 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).
Male
OR
• Contact between the mouth and the penis, vulva, or
anus;
Female
OR
Inmates on
December 31, 2016 . .
• Penetration of the anal or genital opening of another
person however slight, by a hand, finger, object, or other
instrument.
b. ADMITTED to your facility during 2016?
• 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.
ABUSIVE SEXUAL CONTACT
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
• INCLUDE repeat offenders booked on new charges.
AND
• EXCLUDE returns from escape, work release, medical
appointments/treatment facilities, and bail or court
appearances.
Male
Female
• EXCLUDE incidents in which the contact was incidental
to a physical altercation.
New admissions
during 2016 . . . . . . .
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
directed toward another.
2. Between January 1, 2016, and
December 31, 2016, 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, 2016, through December 31, 2016, and
divide the result by 365.
Male
Female
Average daily
population . . . . . . . . . . .
FORM SSV-4 (4-26-2017)
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks of any person.
Page 2
3. Does your facility record allegations of
inmate-on-inmate NONCONSENSUAL SEXUAL
ACTS? (See definitions on page 2.)
Yes
01
6. Does your facility record allegations of
inmate-on-inmate ABUSIVE SEXUAL
CONTACT? (See definitions on page 2.)
➔ a. Do you record all reported occurrences,
01
01
All
02
Substantiated only
b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS
or only completed ones?
02
No
Yes
or only substantiated ones?
01
Both attempted and completed
02
Completed only
02
No
➔ Can these be counted separately from
allegations of NONCONSENSUAL
SEXUAL ACTS?
01
Yes
02
No
➔ Skip to Item 9.
➔ Please provide an explanation in the space
below and then skip to Item 9.
➔ Please provide the definition used by your facility
for inmate-on-inmate NONCONSENSUAL
SEXUAL ACTS in the space below. Use that
definition to complete Items 4 and 5.
7. Between January 1, 2016, and
December 31, 2016, how many allegations
of inmate-on-inmate ABUSIVE SEXUAL
CONTACT were reported?
4. Between January 1, 2016, and
December 31, 2016, how many allegations
of inmate-on-inmate NONCONSENSUAL
SEXUAL ACTS were reported?
Number reported . . . . .
None
• If an allegation involved multiple victimizations, count
only once.
• Exclude any allegations that were reported as consensual.
Number reported . . . . . .
None
• If an allegation involved multiple victimizations, 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.)
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.)
a. Substantiated . . . . . . .
None
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
b. Unsubstantiated . . . . .
....
None
None
None
• The investigation concluded that evidence was insufficient
to determine whether or not the event occurred.
c. Unfounded
.........
c. Unfounded . . . . . . . . . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items 8a
through 8d) . . . . . . . . . .
None
None
• The investigation determined that the event did NOT occur.
d. Investigation ongoing
None
• 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) . . . . . . . . .
None
• The total should equal the number reported in Item 7.
• The total should equal the number reported in Item 4.
FORM SSV-4 (4-26-2017)
Page 3
Section III – STAFF-ON-INMATE SEXUAL ABUSE
9. Does your facility record allegations of
inmate-on-inmate SEXUAL HARASSMENT? (See
definitions on page 2.)
01
02
Yes
No
DEFINITIONS
➔ Do you record all reported
The survey utilizes the definition of “sexual abuse” by a staff
member, contractor or volunteer as provided by 28 C.F.R.
§115.6 in the National Standards to Prevent, Detect, and
Respond to Prison Rape (under the Prison Rape Elimination
Act of 2003). For purposes of SSV, sexual abuse is
disaggregated into two categories of staff-on-inmate sexual
abuse. These categories are:
allegations or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Section III.
STAFF SEXUAL MISCONDUCT
Any behavior or act of a sexual nature directed toward an
inmate by an employee, volunteer, contractor, official visitor
or other agency representative (exclude family, friends or
other visitors).
Sexual relationships of a romantic nature between staff and
inmates are included in this definition. Consensual or
nonconsensual sexual acts include—
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks that is unrelated to official duties or with the
intent to abuse, arouse, or gratify sexual desire;
OR
• Completed, attempted, threatened, or requested sexual acts;
OR
10. Between January 1, 2016, and
December 31, 2016, how many allegations of
inmate-on-inmate SEXUAL HARASSMENT
were reported?
• Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reason unrelated to official duties
or for sexual gratification.
STAFF SEXUAL HARASSMENT
Number reported . . . . . . .
None
• If an allegation involved multiple victims or inmate
perpetrators, count only once.
• Exclude any allegations that were reported as consensual.
Repeated verbal statements, comments or gestures of a sexual
nature to an inmate by an employee, volunteer, contractor,
official visitor, or other agency representative (exclude family,
friends, or other visitors). Include—
• Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;
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.)
OR
• Repeated profane or obscene language or gestures.
a. Substantiated . . . . . .
None
b. Unsubstantiated . . . .
None
c. Unfounded . . . . . . . . . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items 11a
through 11d) . . . . . . . . .
None
• The total should equal the number reported in Item 10.
FORM SSV-4 (4-26-2017)
Page 4
12. Does your facility record allegations of STAFF
SEXUAL MISCONDUCT? (See definitions on page 4.)
01
02
Yes
No
15. Does your facility record allegations of STAFF
SEXUAL HARASSMENT? (See definitions on page 4.)
➔ Do you record all reported
01
occurrences, or only substantiated
ones?
Yes
➔ Can these allegations be counted
separately from allegations of
STAFF SEXUAL MISCONDUCT?
01
All
01
Yes
02
Substantiated only
02
No ➔ Skip to Item 18.
➔ Please provide an explanation in the space
02
below and then skip to Item 15.
➔ Please provide an explanation in the space
below and skip to Item 18.
13. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
Number reported . . . . . .
No
16. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL HARASSMENT were reported?
None
Number reported
• If an allegation involved multiple victimizations, count
only once.
.....
None
• If an allegation involved multiple victims or staff, count
only once.
14. Of the allegations reported in Item 13, how
many were — (Please contact the agency or office
responsible for investigation allegations of sexual
victimization in order to fully complete this form.)
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.)
None
a. Substantiated . . . . . . . .
None
.....
None
b. Unsubstantiated
.....
None
c. Unfounded . . . . . . . . . .
None
c. Unfounded
..........
None
d. Investigation ongoing .
None
d. Investigation ongoing
.
None
e. TOTAL (Sum of Items 14a
through 14d) . . . . . . . . . .
None
e. TOTAL (Sum of Items 17a
through 17d) . . . . . . . . . .
None
a. Substantiated
.......
b. Unsubstantiated
• The total should equal the number reported in Item 13.
FORM SSV-4 (4-26-2017)
Page 5
• The total should equal the number reported in Item 16.
Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
NOTES
18. What is the total number of substantiated
incidents reported in Items 5a, 8a, 11a,
14a, and 17a?
Total substantiated
incidents . . . . . . . . . . . . . .
None
➔ Please complete a Substantiated Incident
Form (Adult, SSV-IA) for each substantiated
incident of sexual victimization.
FORM SSV-4 (4-26-2017)
Clear Fields
Page 6
Print Form
Save As
OMB No. 1121-0292: Approval Expires 4/30/2018
U.S. DEPARTMENT OF JUSTICE
SSV-5
FORM
(5-11-2017)
BUREAU OF JUSTICE STATISTICS
SURVEY OF SEXUAL VICTIMIZATION, 2016
State Juvenile Systems
Summary Form
AND ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
DATA SUPPLIED BY
TELEPHONE
E-MAIL
ADDRESS
City
Number and street or P.O. Box/Route Number
Area code
Number
FAX
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, 2016,
and December 31, 2016.
• 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 ) the box beside each
figure.
• Sections II, III, and V: if the answer to a question is
"none" or "zero," write "0" or mark the box ( X )
provided.
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 Greta Clark at the
U.S. Census Bureau toll-free at 1–800–253–2078 or
email govs.ssv@census.gov
• Please return your completed summary and
substantiated incident forms by
August 15, 2017.
• You may complete these forms online (see
enclosed instructions). Or if you prefer, you
may return these forms by mail or fax.
• 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.
2. On December 31, 2016, 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, 2016.
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, 2016, 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
• 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, 2016.
1. On December 31, 2016, how many facilities
operated by your State held juveniles or
youthful offenders CHARGED WITH or
COURT-ADJUDICATED FOR AN OFFENSE?
Number of facilities
...
4. Between January 1, 2016, and December 31, 2016,
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 (5-11-2017)
Page 2
Section II – YOUTH–ON–YOUTH SEXUAL VICTIMIZATION 5. Does your State juvenile system record
allegations of youth-on-youth NONCONSENSUAL
SEXUAL ACTS?
DEFINITIONS
01
The survey utilizes the definition of “sexual abuse” as
provided by 28 C.F.R. §115.6 in the National Standards to
Prevent, Detect, and Respond to Prison Rape (under the
Prison Rape Elimination Act of 2003). For purposes of SSV,
sexual abuse is disaggregated into three categories of
youth-on-youth sexual victimization. These categories are:
Yes ➔ a. Do you record all reported
occurrences, or only
substantiated ones?
01
02
All
Substantiated only
b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS
or only completed ones?
NONCONSENSUAL SEXUAL ACTS
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
01
AND
• Sexual contact between the penis and the vulva or the
penis and the anus including penetration, however slight;
OR
02
02
No
Both attempted and completed
Completed only
➔ Please provide the definition used by your
State juvenile system for youth-on-youth
NONCONSENSUAL SEXUAL ACTS in the
space below. Use that definition to complete
Items 6 and 7.
• Contact between the mouth and the penis, vulva, or
anus;
OR
• Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument.
ABUSIVE SEXUAL CONTACT
6. Between January 1, 2016, and December 31, 2016,
how many allegations of youth-on-youth
NONCONSENSUAL SEXUAL ACTS were reported?
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
AND
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks of any person.
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 youth directed toward another.
None
• If an allegation involved multiple victimizations, count
only once.
• Exclude any allegations that were reported as
consensual.
• EXCLUDE incidents in which the contact was incidental
to a physical altercation.
SEXUAL HARASSMENT
......
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.)
None
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
None
....
• The investigation concluded that evidence was
insufficient to determine whether or not the event
occured.
None
c. Unfounded . . . . . . . . .
• The investigation determined that the event did NOT
occur.
d. Investigation ongoing
.
None
• 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) . . . . . . . .
None
• The total should equal the number reported in
Item 6.
FORM SSV-5 (5-11-2017)
Page 3
8. Does your State juvenile system record
allegations of youth-on-youth ABUSIVE SEXUAL
CONTACT? (See definitions on page 3.)
11. Does your State juvenile system record
allegations of youth-on-youth SEXUAL
HARASSMENT? (See definitions on page 2.)
01
01
02
Yes
No
Yes
from allegations of
NONCONSENSUAL SEXUAL ACTS?
01
Yes
02
No
➔ Do you record all reported allegations
or only substantiated ones?
➔ Can these be counted separately
➔ Skip to Item 11.
02
➔ Please provide an explanation in the space
No
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Section III.
below and then skip to Item 11.
9. Between January 1, 2016, and
December 31, 2016, how many allegations
of youth-on-youth ABUSIVE SEXUAL
CONTACT were reported?
12. Between January 1, 2016, and
December 31, 2016, how many allegations of
youth-on-youth SEXUAL HARASSMENT
were reported?
Number reported . . . . . .
None
• If an allegation involved multiple victims or youth
perpetrators, count only once.
Number reported . . . . . .
None
• If an allegation involved multiple victimizations, 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.)
• Exclude any allegations that were reported as
consensual.
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.)
.......
None
a. Substantiated . . . . . . .
None
b. Unsubstantiated . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded . . . . . . . . . .
None
c. Unfounded
.........
None
d. Investigation ongoing . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
10a through 10d) . . . . . . .
None
e. TOTAL (Sum of Items
13a through 13d) . . . . . . .
None
a. Substantiated
• The total should equal the number reported in
Item 9.
FORM SSV-5 (5-11-2017)
• The total should equal the number reported in
Item 12.
Page 4
Section III – STAFF-ON-YOUTH SEXUAL ABUSE
14. Does your State juvenile system record
allegations of STAFF SEXUAL MISCONDUCT?
01
DEFINITIONS
The survey utilizes the definition of “sexual abuse” by a staff
member, contractor or volunteer as provided by 28 C.F.R.
§115.6 in the National Standards to Prevent, Detect, and
Respond to Prison Rape (under the Prison Rape Elimination
Act of 2003). For purposes of SSV, sexual abuse is
disaggregated into two categories of staff-on-youth sexual
abuse. These categories are:
02
Yes
No
➔ Do you record all reported
occurrences, or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Item 17.
STAFF SEXUAL MISCONDUCT
Any behavior or act of a sexual nature directed toward a
youth by an employee, volunteer, contractor, official visitor or
other agency representative (exclude family, friend or other
visitors).
Sexual relationships of a romantic nature between staff and
youths are included in this definition. Consensual or
nonconsensual sexual acts include—
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks that is unrelated to official duties or with the
intent to abuse, arouse, or gratify sexual desire;
15. Between January 1, 2016, and
December 31, 2016, how many allegations
of STAFF SEXUAL MISCONDUCT were
reported?
Number reported . . . . . .
OR
• Completed, attempted, threatened, or requested sexual
acts;
OR
• Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reasons unrelated to official duties
or for sexual gratification.
None
• If an allegation involved multiple victimizations, 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.)
STAFF SEXUAL HARASSMENT
Repeated verbal statements, comments or gestures of a
sexual nature to a youth by an employee, volunteer,
contractor, official visitor, or other agency representative
(exclude family, friends, or other visitors). Include—
• Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;
a. Substantiated . . . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded . . . . . . . . . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items
16a through 16d) . . . . . . .
None
OR
• Repeated profane or obscene language or gestures.
• The total should equal the number reported in
Item 15.
FORM SSV-5 (5-11-2017)
Page 5
17. Does your State juvenile system record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 5.)
01
02
Yes
No
Section IV – PRIVATE AND LOCAL ALLEGATIONS
20. Did any of the allegations reported in Items 6, 9,
12, 15, or 18 occur in a privately operated
facility?
➔ Can these allegations be counted
separately from allegations of
STAFF SEXUAL MISCONDUCT?
01
Yes
02
No
➔ Skip to Item 20.
01
Yes
02
No
21. Did any of the allegations reported in Items 6, 9,
12, 15, or 18 occur in a facility operated or
administered by local governments?
➔ Please provide an explanation in the space
below and then skip to Item 20.
01
Yes
02
No
Section V – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
22. What is the total number of substantiated
incidents reported in Items 7a, 10a, 13a,
16a, and 19a?
18. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL HARASSMENT were reported?
Number reported . . . . . .
Total substantiated
incidents . . . . . . . . . . . . .
None
➔ Please complete a Substantiated Incident Form
(Juvenile, SSV-IJ) for each substantiated
incident of sexual victimization.
• If an allegation involved multiple victims or staff, count
only once.
19. Of the allegations reported in Item 18, 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 . . . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded
.........
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items 19a
through 19d) . . . . . . . . . .
None
None
NOTES
• The total should equal the number reported in
Item 18.
FORM SSV-5 (5-11-2017)
Clear Fields
Page 6
Print Form
Save As
OMB No. 1121-0292: Approval Expires 4/30/2018
U.S. DEPARTMENT OF JUSTICE
SSV-6
FORM
(5-11-2017)
SURVEY OF SEXUAL VICTIMIZATION, 2016
Locally or Privately-Operated Juvenile Facilities
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Economics and Statistics Administration
Summary Form
U.S. CENSUS BUREAU
DATA SUPPLIED BY
TELEPHONE
E-MAIL
ADDRESS
City
Number and street or P.O. Box/Route Number
Area code
Number
FAX
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" or mark the box ( X ) provided.
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, 2016, and December 31, 2016.
• 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 Greta Clark at the
U.S. Census Bureau toll–free at 1–888–369–3613,
option 2, or e-mail govs.ssv@census.gov
• Please return your completed summary and
substantiated incident forms by
August 15, 2017.
• You may complete these forms online (see
enclosed instructions). Or if you prefer, you
may return these forms by mail or fax.
• 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, 2016, 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, 2016.
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, 2016, 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.
c. Age 21 or older . . . . . . . . . .
Section I – GENERAL INFORMATION
d. TOTAL (Sum of Items 4a through
4c should equal Item 3c) . . . . . .
1. Is this facility owned by a —
01
Private agency
02
Native American Tribal Government
03
State
04
County
05
Local or municipal government
06
Other – Specify
............
• 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, 2016.
5. Between January 1, 2016, and
December 31, 2016, 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
02
Native American Tribal Government
03
State
04
County
05
Local or municipal government
06
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 (5-11-2017)
Page 2
Section II – YOUTH-ON-YOUTH SEXUAL VICTIMIZATION 6. Does your facility record allegations of
youth-on-youth NONCONSENSUAL SEXUAL
ACTS?
DEFINITIONS
01
Yes ➔ a. Do you record all reported
The survey utilizes the definition of “sexual abuse” as
occurrences, or only
provided by 28 C.F.R. §115.6 in the National Standards to
substantiated ones?
Prevent, Detect, and Respond to Prison Rape (under the
Prison Rape Elimination Act of 2003). For purposes of SSV,
01
All
sexual abuse is disaggregated into three categories of
Substantiated only
02
youth-on-youth sexual victimization. These categories are:
b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS
or only completed ones?
NONCONSENSUAL SEXUAL ACTS
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
01
02
AND
• Contact between the penis and the vulva or the penis
and the anus including penetration, however slight;
02
No
Both attempted and completed
Completed only
➔ Please provide the definition used by your
facility for youth-on-youth NONCONSENSUAL
SEXUAL ACTS in the space below. Use that
definition to complete Items 7 and 8.
OR
• Contact between the mouth and the penis, vulva, or
anus;
OR
• Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or
other instrument.
7. Between January 1, 2016 and December 31, 2016,
how many allegations of youth-on-youth
NONCONSENSUAL SEXUAL ACTS were reported?
ABUSIVE SEXUAL CONTACT
Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;
Number reported . . . . . .
AND
• If an allegation involved multiple victimizations, count only
once.
• Intentional touching, either directly or through the
clothing, of the genitalia, anus, groin, breast, inner thigh,
or buttocks of any person.
• EXCLUDE incidents in which the contact was incidental
to a physical altercation.
SEXUAL HARASSMENT
None
• 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.)
Repeated and unwelcome sexual advances, requests for
sexual favors, or verbal comments, gestures, or actions
of a derogatory or offensive sexual nature by one youth
directed toward another.
a. Substantiated
None
......
• The event was investigated and determined to have
occurred, based on a preponderance of the evidence
(28 C.F.R. §115.72).
b. Unsubstantiated
None
....
• The investigation concluded that evidence was insufficient
to determine whether or not the event occurred.
None
c. Unfounded . . . . . . . . .
• The investigation determined that the event did NOT occur.
d. Investigation ongoing
.
None
• 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) . . . . . . . .
None
• The total should equal the number reported in Item 7.
FORM SSV-6 (5-11-2017)
Page 3
9. Does your facility record allegations of
youth-on-youth ABUSIVE SEXUAL CONTACT?
(See definitions on page 3.)
01
02
Yes
No
12. Does your facility record allegations of
youth-on-youth SEXUAL HARASSMENT?
(See definitions on page 3.)
➔ Can these be counted separately
01
from allegations of
NONCONSENSUAL SEXUAL ACTS?
01
Yes
02
No
Yes
➔ Do you record all reported
allegations or only substantiated
ones?
➔ Skip to Item 12.
➔ Please provide an explanation in the space
02
below and then skip to Item 12.
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Section III.
10. Between January 1, 2016, and
December 31, 2016, how many allegations of
youth-on-youth ABUSIVE SEXUAL CONTACT
were reported?
Number reported . . . . . .
No
01
13. Between January 1, 2016, and
December 31, 2016, how many allegations of
youth-on-youth SEXUAL HARASSMENT were
reported?
Number reported . . . . . .
None
None
• If an allegation involved multiple victimizations, count
only once.
• If an allegation involved multiple victims or youth
perpetrators, count only once.
• Exclude any allegations that were reported as consensual.
• Exclude any allegations that were reported as consensual.
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.)
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 . . . . . . .
None
a. Substantiated . . . . . . .
None
b. Unsubstantiated . . . . .
None
b. Unsubstantiated
....
None
c. Unfounded
None
c. Unfounded
.........
None
d. Investigation ongoing . .
None
d. Investigation ongoing
e. TOTAL (Sum of Items
11a through 11d) . . . . . . .
None
e. TOTAL (Sum of Items
14a through 14d) . . . . . . .
.........
• The total should equal the number reported in Item 10.
FORM SSV-6 (5-11-2017)
.
None
None
• The total should equal the number reported in Item 13.
Page 4
Section III – STAFF-ON-YOUTH SEXUAL ABUSE
15. Does your facility record allegations of STAFF
SEXUAL MISCONDUCT?
DEFINITIONS
Yes
01
The survey utilizes the definition of “sexual abuse” by a staff
member, contractor or volunteer as provided by 28 C.F.R.
§115.6 in the National Standards to Prevent, Detect, and
Respond to Prison Rape (under the Prison Rape Elimination
Act of 2003). For purposes of SSV, sexual abuse is
disaggregated into two categories of staff-on-youth sexual
abuse. These categories are:
02
STAFF SEXUAL MISCONDUCT
No
➔ Do you record all reported
occurrences, or only substantiated
ones?
01
All
02
Substantiated only
➔ Please provide an explanation in the space
below and then skip to Item 18.
Any behavior or act of a sexual nature directed toward a youth by
an employee, volunteer, contractor, official visitor or other agency
representative (exclude family, friends or other visitors).
Sexual relationships of a romantic nature between staff and
youths are included in this definition. Consensual or
nonconsensual sexual acts include–
• Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
that is unrelated to official duties or with the intent to abuse,
arouse, or gratify sexual desire;
OR
• Completed, attempted, threatened, or requested sexual acts;
OR
16. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
• Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reasons unrelated to official duties
or for sexual gratification.
Number reported . . . . . .
• If an allegation involved multiple victimizations, count only
once.
STAFF SEXUAL HARASSMENT
Repeated verbal statements, comments or gestures of a sexual
nature to a youth by an employee, volunteer, contractor, official
visitor, or other agency representative (exclude family, friends,
or other visitors). Include–
• Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;
None
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
OR
......
None
• Repeated profane or obscene language or gestures.
....
None
c. Unfounded . . . . . . . . .
None
d. Investigation ongoing
None
e. TOTAL (Sum of Items
17a through 17d) . . . . . .
None
b. Unsubstantiated
• The total should equal the number reported in Item 16.
FORM SSV-6 (5-11-2017)
Page 5
Section IV – TOTAL SUBSTANTIATED
INCIDENTS OF SEXUAL VICTIMIZATION
18. Does your facility record allegations of STAFF
SEXUAL HARASSMENT ? (See definitions on page 5.)
Yes
01
No
02
➔ Can these allegations be counted
21. What is the total number of substantiated
incidents reported in Items 8a, 11a, 14a,
17a, and 20a.
separately from allegations of
STAFF SEXUAL MISCONDUCT?
01
Yes
02
No
➔ Skip to Item 21
Total substantiated
incidents . . . . . . . . . . . . .
None
➔ Please provide an explanation in the space
below and then skip to Item 21.
➔ Please complete a Substantiated Incident Form
(Juvenile, SSV-IJ) for each substantiated
incident of sexual victimization.
NOTES
19. Between January 1, 2016, and
December 31, 2016, how many allegations of
STAFF SEXUAL HARASSMENT were reported?
Number reported . . . . . .
None
• If an allegation involved multiple victims or staff, count
only once.
20. Of the allegations reported in Item 19, 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 . . . . . . .
None
b. Unsubstantiated . . . . .
None
c. Unfounded . . . . . . . . . .
None
d. Investigation ongoing .
None
e. TOTAL (Sum of Items 20a
through 20d) . . . . . . . . . .
None
•
The total should equal the number reported in Item 19.
FORM SSV-6 (5-11-2017)
Clear Fields
Page 6
Print Form
Save As
OMB No. 1121-0292: Approval Expires 04/30/2018
SSV-IA
FORM
(4-27-2017)
U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
SURVEY OF SEXUAL VICTIMIZATION, 2016
and ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Substantiated Incident Form (Adult)
Economics and Statistics Admin.
U.S. CENSUS BUREAU
See item 25 on page 3
Incident Number ___ out of ___
1. On what date did the incident occur?
(If more than one date, report the most recent.)
Month Day
Year
6. How many victims were involved in the incident?
Number of victims . . .
➔ If more than two victims were involved,
report their characteristics in Notes on page 5.
2. In what facility did the incident occur?
Name
7. Victim #1: What was the victim’s sex or gender
identity? (See definitions on page 5.)
City/Place
3. Where did the incident occur? (Mark ( X ) all that apply.)
01
In the victim’s cell or room (e.g., if the victim and perpetrator
share a cell or room, count as the victim’s cell)
02
In the perpetrator’s cell or room
In a dormitory or other multiple housing unit
03
04
05
06
07
08
09
10
11
12
13
02
03
Male
03
Transgender
02
Female
04
Intersex
8. Victim #1: What was the victim’s age at the
time of the incident?
01
02
03
Under age 18
18 – 24
25 – 29
30 – 34
05
06
07
35 – 39
40 – 44
45 – 54
55 or older
08
04
In a common area (e.g., shower, dayroom, bathroom)
In a temporary holding cell or intake area within the
facility
9. Victim #1: What was the victim’s race/ethnic origin?
In a program service area (e.g., commissary, kitchen,
(Mark ( X ) all that apply.)
storage, laundry, cafeteria, workshop, hallway)
White (not of Hispanic origin)
01
In an instructional area (e.g., classroom, school, library,
Black (not of Hispanic origin)
02
conference room)
Hispanic or Latino
03
In a recreation area (e.g., yard, courtyard, gymnasium)
American Indian/Alaska Native (not of Hispanic origin)
04
In a medical area (e.g., infirmary, health clinic)
Asian (not of Hispanic origin)
05
In a staff area (e.g., office, break room, counselor’s office)
Native Hawaiian or Other Pacific Islander
06
(not of Hispanic origin)
Offsite or while in transit
Other racial category in your information system –
07
Other – Specify
Specify
Location unknown
4. Did the incident take place in an area subject to
video monitoring?
01
01
Yes
No
Don’t know
5. What time did the incident occur?
(Mark ( X ) all that apply.)
01
Morning (6 a.m. to noon)
02
Afternoon (noon to 6 p.m.)
03
Evening (6 p.m. to midnight)
Overnight (midnight to 6 a.m.)
04
Time unknown
05
10. Victim #2: What was the victim’s sex or gender
identity? (See definitions on page 5.)
01
Male
03
Transgender
02
Female
04
Intersex
11. Victim #2: What was the
time of the incident?
05
01
Under age 18
06
02
18 – 24
03
25 – 29
07
30 – 34
04
08
victim’s age at the
35 – 39
40 – 44
45 – 54
55 or older
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.
12. Victim #2: What was the victim’s race/ethnic origin?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
Specify
15. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
Given a medical examination
02
Administered a rape kit
03
Tested for HIV/AIDS
04
Tested for other sexually transmitted diseases
05
Provided with counseling or mental health
treatment
06
Offered but declined testing or treatment
07
Already released/discharged
08
None of the above
16. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
13. Did the victim(s) sustain any physical injury
during the incident?
02
01
No (No injury sustained)
Yes ➔ a. What injuries occurred?
(Mark ( X
x ) all that apply for all victims.)
Knife or stab wounds
01
Broken bones
02
Anal or vaginal tearing
03
Chipped or knocked out teeth
04
Internal injuries
05
Knocked unconscious
06
07
Bruises, black eye, sprains, cuts,
scratches, swelling, welts
08
Other – Specify
➔ b. Did the victim(s) receive medical
treatment for these injuries?
01
Yes
02
No
14. Who reported the incident?
(Mark ( X) all that apply.)
01
Victim
Another inmate (non-victim)
02
Victim’s family or friend
03
Correctional officer or front line staff
04
Administrative staff
05
Medical, healthcare, or mental health staff
06
Instructor, teacher, or counselor
07
Other staff (e.g., kitchen worker, maintenance staff)
08
Chaplain or other religion official
09
Perpetrator
10
Perpetrator’s family or friend
11
Grievance coordinator, grievance process, or
12
ombudsperson
Attorney or legal guardian (e.g., other than family member)
13
Confidential informant, anonymous tip, hot line, or
14
through monitoring (e.g., camera, telephone, or mail)
Other – Specify
15
Page 2
01
02
03
04
05
06
07
08
Placed in or returned to administrative segregation,
protective custody, or disciplinary segregation
Placed in a medical unit, ward, or hospital
Confined to own cell or room
Given a higher custody level or different unit within
the facility
Transferred to another facility
Transferred to another housing unit or dorm, or
given a single room or cell
Separated from perpetrator
Issued disciplinary report or loss of privileges
10
Placed in camera room, under closer surveillance,
or increased supervision
Other – Specify
11
None of the above
09
17. What type of sexual violence was involved in
the incident? (See definitions on page 5.)
01
02
03
04
05
Inmate-on-inmate nonconsensual sexual act
→ Complete Section A, below
Inmate-on-inmate abusive sexual contact
→ Complete Section A, below
Inmate-on-inmate sexual harassment
→ Complete Section A, below
Staff sexual misconduct
→ Complete Section B on pages 4–5
Staff sexual harassment
→ Complete Section B on pages 4–5
Section A – INMATE-ON-INMATE SEXUAL VICTIMIZATION
➞ If the perpetrator was a staff member, go
to Section B on pages 4–5.
18. How many inmate perpetrators were involved
in the incident?
Number of inmate perpetrators . . . .
➞ If more than two inmate perpetrators were
involved, report their characteristics in
Notes on page 5.
FORM SSV-IA (4-27-2017)
25. What was the nature of the incident?
(Mark ( X ) all that apply.)
19. Perpetrator #1: What was the inmate
perpetrator’s sex or gender identity?
(See definitions on page 5.)
01
01
Male
03
Transgender
02
02
Female
04
Intersex
03
20. Perpetrator #1: What was the inmate
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
07
08
45–54
55 or older
02
03
04
05
06
07
05
06
07
08
21. Perpetrator #1: What was the inmate
perpetrator’s race/ethnic origin?
(Mark ( X) all that apply.)
01
04
09
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
01
Male
03
Transgender
02
Female
04
Intersex
05
Bribery or blackmail
Gave victim drugs or alcohol
06
Offered protection from other inmates
07
11
Threatened with physical harm
Physically held victim down or restrained in
some way
Physically harmed or injured
Threatened with a weapon
Other – Specify
12
None
08
09
23. Perpetrator #2: What was the inmate
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
07
08
02
03
04
05
06
07
10
45–54
55 or older
24. Perpetrator #2: What was the inmate
perpetrator’s race/ethnic origin?
(Mark ( X ) all that apply.)
01
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic Origin)
Other racial category in your information system –
Specify
27. 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 or room
03
Placed in higher custody level, restricted unit or
program, within the same facility
04
Transferred to other unit/cell or separated from victim
Transferred to another facility
05
06
07
08
09
10
11
12
13
FORM SSV-IA (4-27-2017)
Unwanted touching for sexual gratification or
abusive sexual contact
Pressure or coercion (without force) resulting in a
nonconsensual sexual act
Physical force (or the threat of force) resulting
in a nonconsensual sexual act
Other – Specify
26. What type of pressure or physical force was
used by the inmate perpetrator on the victim?
(Mark ( X) all that apply for all perpetrators.)
Sexual harassment, sexual innuendo, or verbal
01
comments
Persuasion or talked into sexual activity
02
03
Surprised the victim with unwanted touching,
grabbing or groping, or victim was asleep
04
22. Perpetrator #2: What was the inmate
perpetrator’s sex or gender identity?
(See definitions on page 5.)
Voluntary sexual contact between inmates
Sexual harassment
Indecent exposure, masturbation, or voyeurism
Horseplay
Repeated and unwelcome sexual advances or
requests for sexual favors
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
Sent to counseling or treatment team
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, given new sentence, or fined
Other – Specify
Page 3
Section B – STAFF-ON-INMATE SEXUAL ABUSE
➔ If the perpetrator was an inmate, go to
Section A on pages 2–3.
28. What was the nature of the incident?
(Mark ( X) all that apply.)
01
02
03
04
05
06
07
08
09
33. Staff #2: What was the gender of the staff?
01
Male
02
Female
34. Staff #2: What was the age of the staff at the
time of the incident?
24 or younger
01
40 – 44
05
Physical force resulting in a nonconsensual
25 – 29
02
45 – 54
06
sexual act
30 – 34
03
07
55 or older
Pressure or abuse of power resulting in a
35 – 39
04
nonconsensual sexual act
Indecent exposure, invasion of privacy, or
35. Staff #2: What was the race/ethnic origin of the
voyeurism for sexual gratification
staff involved in the incident?
(Mark ( X) all that apply.)
Unwanted touching for sexual gratification
White (not of Hispanic origin)
01
Sexual harassment or repeated verbal statements
of a sexual nature by staff
02
Black (not of Hispanic origin)
Wrote letters, showed pictures, or
03
Hispanic or Latino
offered gifts or special privileges to inmate
American Indian/Alaska Native (not of Hispanic
04
Sexual relationship between inmate and staff
origin)
that appeared to be willing
05
Asian (not of Hispanic origin)
Other – Specify
Native Hawaiian or Other Pacific Islander
06
(not of Hispanic origin)
07
Other racial category in your information system –
Specify
Level of coercion unknown
29. How many staff were involved in the incident?
Number of staff . . . .
➔ If more than two staff were involved, report
their characteristics in Notes on page 5.
36. Was the staff involved in the incident an employee
of the facility, a contractor, or a volunteer?
(Mark ( X) all that apply for all staff involved.)
01
02
30. Staff #1: What was the gender of the staff?
01
Male
02
Female
03
04
Full– or part–time paid employee
Contract employee or vendor
Volunteer or intern
Other – Specify
31. Staff #1: What was the age of the staff at the
time of the incident?
01
02
03
04
24 or younger
25 – 29
30 – 34
35 – 39
05
06
07
40 – 44
45 – 54
55 or older
32. Staff #1: What was the race/ethnic origin of the
staff involved in the incident?
(Mark ( X) all that apply.)
01
02
03
04
05
06
07
Page 4
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
37. What was the primary position description of
the staff involved in the incident?
(Mark ( X) all that apply for all staff involved.)
01
02
03
04
05
06
07
08
09
Administrator, including wardens, superintendents,
assistants and others in administrative positions
Correctional officer or supervisory staff
Clerical staff including secretaries, clerks,
receptionists, and other administrative support
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
Medical or health care staff, including counselors,
doctors, dentists, psychologists, psychiatrists,
social workers, nurses, and medical assistants
Education staff, including instructors, teachers,
librarians, and education assistants
Other program staff
Volunteers or Interns
Other staff – Specify
FORM SSV-IA (4-27-2017)
Definitions
38. What sanction was imposed on the staff?
(Mark ( X ) all that apply for all staff involved.)
11
Sent to training or counseling
Reprimanded or disciplined
Demoted, diminished responsibilities, or
suspended temporarily
Transferred to another facility or unit
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, sentenced, or fined
Discharged, terminated, or contract not renewed
Staff resigned (prior to completion of investigation)
Staff resigned (after investigation was completed)
Other – Specify
12
No action taken
01
02
03
04
05
06
07
08
09
10
39. At the time of the incident, how long had the
staff worked at the facility?
(Mark ( X ) all that apply for all staff involved.)
01
Less than 6 months
6 months to 1 year
02
1 to 5 years
03
5 to 10 years
04
More than 10 years
05
NOTES
Sexual victimization
NONCONSENSUAL SEXUAL ACTS: Sexual contact of any
person without his or her consent, or of a person who is
unable to consent or refuse;
AND
Contact between the penis and the vulva or the penis
and the anus including penetration, however slight; OR
Contact between the mouth and the penis, vulva, or anus;
OR
Penetration of the anal or genital opening of another person,
however slight, by a hand, finger, object, or other
instrument.
ABUSIVE SEXUAL CONTACT (less severe): Sexual
contact of any person without his or her consent, or of a
person who is unable to consent or refuse;
AND
Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
of any person.
EXCLUDE incidents in which the contact was incidental to a
physical altercation.
SEXUAL HARASSMENT BY ANOTHER INMATE: Repeated
and unwelcome sexual advances, requests for sexual favors,
or verbal comments, gestures, or actions of a derogatory or
offensive sexual nature by one inmate directed toward
another.
STAFF SEXUAL MISCONDUCT: Any behavior or act of a
sexual nature directed toward an inmate by an employee,
volunteer, contractor, official visitor or other agency
representative (exclude family, friends or other visitors).
Sexual relationships of a romantic nature between staff and
inmates are included in this definition. Consensual or
nonconsensual sexual acts include—
Intentional touching, either directly or through the clothing,
of the genitalia, anus, groin, breast, inner thigh, or buttocks
that is unrelated to official duties or with the intent to
abuse, arouse, or gratify sexual desire;
OR
Completed, attempted, threatened, or requested sexual acts;
OR
Occurrences of indecent exposure, invasion of privacy, or
staff voyeurism for reasons unrelated to official duties or for
sexual gratification.
STAFF SEXUAL HARASSMENT: Repeated verbal
comments or gestures of a sexual nature to an inmate by an
employee, volunteer, contractor, official visitor, or other
agency representative (excludes family, friends, or other
visitors). Include demeaning references to gender; or sexually
suggestive or derogatory comments about body or clothing;
OR
Repeated profane or obscene language or gestures.
Gender categories
TRANSGENDER: A person whose gender identity (i.e.,
internal sense of feeling male or female) is different from
the person’s assigned sex at birth.
INTERSEX: A person whose sexual or reproductive anatomy or
chromosomal pattern does not seem to fit typical definitions of
male or female. Intersex medical conditions are sometimes
referred to as disorders of sex development.
FORM SSV-IA (4-27-2017)
Save As
Print Form
Clear Fields
Page 5
OMB No. 1121-0292: Approval Expires 04/30/2018
SSV-IJ
FORM
(4-27-2017)
U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
SURVEY OF SEXUAL VICTIMIZATION, 2016
and ACTING AS COLLECTION AGENT
U.S. DEPT. OF COMMERCE
Substantiated Incident Form (Juvenile)
Economics and Statistics Admin.
U.S. CENSUS BUREAU
See item 25 on page 3
Incident Number ___ out of ___
6. How many victims were involved in the incident?
1. On what date did the incident occur?
(If more than one date, report the most recent.)
Month Day
Year
Number of victims . . . .
➔ If more than two victims were involved, report
their characteristics in Notes on page 5.
2. In what facility did the incident occur?
Name
7. Victim #1: What was the victim’s sex or gender
identity? (See definitions on page 5.)
City/Place
01
02
Male
Female
03
04
Transgender
Intersex
3. Where did the incident occur? (Mark ( X ) all that apply.)
01
02
03
04
05
06
07
08
09
10
11
12
13
8. Victim #1: What was the victim’s age at the time
of the incident?
In the victim’s cell or room (e.g., if the victim and
perpetrator share a cell or room, count as the victim’s
01
Under age 13
04
18–19
cell)
05
20–24
02
13–15
In the perpetrator’s cell or room
03
16–17
06
25 or older
In a dormitory or other multiple housing unit
In a common area (e.g., shower, dayroom, bathroom)
In a temporary holding cell or admissions area within 9. Victim #1: What was the victim’s race/ethnic origin?
the facility
(Mark ( X ) all that apply.)
In a program service area (e.g., commissary, kitchen,
White (not of Hispanic origin)
01
storage, laundry, cafeteria, workshop, hallway)
Black (not of Hispanic origin)
02
In an instructional area (e.g., classroom, school, library,
Hispanic or Latino
03
conference room)
04
American Indian/Alaska Native (not of Hispanic origin)
In a recreation area (e.g., yard, courtyard, gymnasium)
05
Asian (not of Hispanic origin)
In a medical area (e.g., Infirmary, health clinic)
06
Native Hawaiian or Other Pacific Islander
In a staff area (office, break room, counselor’s office)
(not of Hispanic origin)
Offsite or while in transit
Other racial category in your information system –
07
Other – Specify
Specify
Location unknown
4. Did the incident take place in an area subject to
video monitoring?
01
02
03
Yes
No
Don’t know
5. What time did the incident occur?
(Mark ( X ) all that apply.)
01
02
03
04
05
Morning (6 a.m. to noon)
Afternoon (noon to 6 p.m.)
Evening (6 p.m. to midnight)
Overnight (midnight to 6 a.m.)
Unknown
10. Victim #2: What was the victim’s sex or gender
identity? (See definitions on page 5.)
01
02
Male
Female
03
04
Transgender
Intersex
11. Victim #2: What was the victim’s age at the time
of the incident?
01
02
03
Under age 13
13–15
16–17
04
05
06
18–19
20–24
25 or older
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.
12. Victim #2: What was the victim’s race/ethnic origin?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
Specify
13. Did the victim(s) sustain any physical injury
during the incident?
02
01
No (No injury sustained)
Yes ➔ a. What injuries occurred?
(Mark ( X ) all that apply for all victims.)
Knife or stab wounds
01
Broken bones
02
Anal or vaginal tearing
03
Chipped or knocked out teeth
04
Internal injuries
05
Knocked unconscious
06
07
Bruises, black eye, sprains, cuts,
scratches, swelling, welts
08
Other – Specify
➔ b. Did the victim(s) receive medical
treatment for these injuries?
01
Yes
02
No
14. Who reported the incident?
(Mark ( X ) all that apply.)
01
Victim
Another youth (non-victim)
02
Victim’s family or friend
03
Correctional officer or front line staff
04
Administrative staff
05
Medical, healthcare, or mental health staff
06
Instructor, teacher, or counselor
07
Other staff (e.g., kitchen worker, maintenance staff)
08
Chaplain or other religious official
09
Perpetrator
10
Perpetrator’s family or friend
11
Grievance coordinator, grievance process, or
12
ombudsperson
Attorney or legal guardian (e.g., other than family
13
member)
Confidential informant, anonymous tip, hot line, or
14
through monitoring (e.g., camera, telephone, or mail)
Other – Specify
15
15. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
Given a medical examination
02
Administered a rape kit
03
Tested for HIV/AIDS
04
Tested for other sexually transmitted diseases
05
Provided with counseling or mental health
treatment
06
Offered but declined testing or treatment
07
Already released/discharged
08
None of the above
16. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
Placed in or returned to administrative segregation,
protective custody, or disciplinary segregation
02
Placed in a medical unit, ward, or hospital
03
Confined to own cell or room
04
Given a higher custody level/different unit within
the facility
05
Transferred to another facility
06
Transferred to another housing unit or dorm, or
given a single room or cell
07
Separated from perpetrator
08
Issued disciplinary report or loss of privileges
09
Placed in camera room, under closer surveillance,
or increased supervision
10
Other – Specify
11
None of the above
17. What type of sexual violence was involved in
the incident? (See definitions on page 5.)
01
Youth–on–youth nonconsensual sexual act
→ Complete Section A, below
02
Youth–on–youth abusive contact
→ Complete Section A, below
03
Youth–on–youth sexual harassment
→ Complete Section A, below
04
Staff sexual misconduct
→ Complete Section B on pages 4–5
05
Staff sexual harassment
→ Complete Section B on pages 4–5
Section A – YOUTH-ON-YOUTH SEXUAL VICTIMIZATION
➞ If the perpetrator was a staff member, go
to Section B on pages 4–5.
18. How many youth perpetrators were involved in
the incident?
Number of youth perpetrators . . . .
➞ If more than two youth perpetrators were
involved, report their characteristics in Notes
on page 5.
Page 2
FORM SSV-IJ (4-27-2017)
19. Perpetrator #1: What was the youth perpetrator’s
sex or gender identity? (See definitions on page 5.)
01
02
Male
Female
03
04
Transgender
Intersex
20. Perpetrator #1: What was the youth perpetrator’s
age at the time of the incident?
01
02
03
Under age 13
13–15
16–17
04
05
06
18–19
20–24
25 or older
21. Perpetrator #1: What was the youth perpetrator’s
race/ethnic origin? (Mark ( X ) all that apply.)
01
02
03
04
05
06
07
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic Origin)
Other racial category in your information system –
Specify
22. Perpetrator #2: What was the youth perpetrator’s
sex or gender identity? (See definitions on page 5.)
01
02
Male
Female
03
04
Transgender
Intersex
23. Perpetrator #2: What was the youth perpetrator’s
age at the time of the incident?
01
02
03
Under age 13
13–15
16–17
04
05
06
18–19
20–24
25 or older
25. What was the nature of the incident?
(Mark ( X ) all that apply.)
01 X
02
03
04
05
06
07
08
09
Voluntary sexual contact between youths
Sexual harassment
Indecent exposure, masturbation, or voyeurism
Horseplay
Repeated and unwelcome sexual advances or
requests for sexual favors
Unwanted touching for sexual gratification or
abusive sexual contact
Pressure or coercion (without force) resulting
in a nonconsensual sexual act
Physical force (or the threat of force) resulting
in a nonconsensual sexual act
Other – Specify
26. What type of pressure or physical force was
used by the youth perpetrator on the victim?
(Mark ( X ) all that apply for all perpetrators.)
01 X Sexual harassment, sexual innuendo, or
verbal comments
Persuasion or talked into sexual activity
02
03
Surprised the victim with unwanted touching,
grabbing or groping, or victim was asleep
04
Bribery or blackmail
05
Gave victim drugs or alcohol
06
Offered protection from other youth
07
Threatened with physical harm
Physically held victim down or restrained in
08
some way
09
Physically harmed or injured
Threatened with a weapon
10
11
Other – Specify
24. Perpetrator #2: What was the youth perpetrator’s
race/ethnic origin? (Mark ( X ) all that apply.)
01
02
03
04
05
06
07
12
None
White (not of Hispanic origin)
Black (not of Hispanic origin)
27. What sanction was imposed on the perpetrator(s)?
Hispanic or Latino
(Mark ( X ) all that apply for all perpetrators.)
American Indian/Alaska Native (not of Hispanic
01
Placed in solitary confinement or disciplinary
origin)
segregation
Asian (not of Hispanic origin)
02
Confined to own cell or room
Native Hawaiian or Other Pacific Islander
03
Placed in higher custody level, restricted unit or
(not of Hispanic Origin)
program, within the same facility
Other racial category in your information system –
04
Transferred to other unit/cell or separated from
Specify
victim
05
Transferred to another facility
06
Loss of "good/gain" time or increase in "bad"
time/delayed release
07
Given extra work
08
Loss of privileges, disciplinary report or conduct
violation, or other reprimand
09
Sent to counseling or treatment team
10
Arrested or referred to law enforcement agency
11
Referred for prosecution or indicted
12
Convicted, given new sentence, or fined
Other – Specify
13
FORM SSV-IJ (4-27-2017)
Page 3
Section B – STAFF-ON-YOUTH SEXUAL ABUSE
➔ If the perpetrator was a youth, go
to Section A on pages 2–3.
28. What was the nature of the incident?
(Mark ( X) all that apply.)
Physical force resulting in a nonconsensual
sexual act
Pressure or abuse of power resulting in a
nonconsensual sexual act
Indecent exposure, invasion of privacy, or
voyeurism for sexual gratification
Unwanted touching for sexual gratification
Sexual harassment or repeated verbal statements
of a sexual nature by staff
Wrote letters, showed pictures, or offered gifts or
special privileges to youth
Sexual relationship between youth and staff
that appeared to be willing
Other – Specify
01
02
03
04
05
06
07
08
33. Staff #2: What was the gender of the staff?
01
02
Female
34. Staff #2: What was the age of the staff at the
time of the incident?
01
02
03
04
24 or younger
25 – 29
30 – 34
35 – 39
05
06
07
40 – 44
45 – 54
55 or older
35. Staff #2: What was the race/ethnic origin of the
staff involved in the incident?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07
Level of coercion unknown
09
Male
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
29. How many staff were involved in the incident?
Number of staff . . . . .
➔ If more than two staff were involved, report
their characteristics in Notes on page 5.
36. Was the staff involved in the incident an employee
of the facility, a contractor, or a volunteer?
(Mark ( X ) all that apply for all staff involved.)
01
02
30. Staff #1: What was the gender of the staff?
01
Male
02
Female
03
04
Full– or part–time paid employee
Contract employee or vendor
Volunteer or intern
Other – Specify
31. Staff #1: What was the age of the staff at the
time of the incident?
01
02
03
04
24 or younger
25 – 29
30 – 34
35 – 39
05
06
07
40 – 44
45 – 54
55 or older
32. Staff #1: What was the race/ethnic origin of the
staff involved in the incident?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07
Page 4
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
37. What was the primary position description of
the staff involved in the incident?
(Mark ( X ) all that apply for all staff involved.)
08
Administrator, including wardens,
superintendents, assistants and others in
administrative positions
Correctional officer or supervisory staff
Clerical staff including secretaries, clerks,
receptionists, and other administrative support
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
Medical or health care staff, including counselors,
doctors, dentists, psychologists, psychiatrists,
social workers, nurses, and medical assistants
Education staff, including instructors, teachers,
librarians, and education assistants
Other program staff
Volunteers or Interns
09
Other staff – Specify
01
02
03
04
05
06
07
FORM SSV-IJ (4-27-2017)
Definitions
38. What sanction was imposed on the staff?
(Mark ( X ) all that apply for all staff involved.)
01
02
03
04
05
Sexual victimization
Sent to training or counseling
Reprimanded or disciplined
Demoted, diminished responsibilities, or
suspended temporarily
Transferred to another facility or unit
Arrested or referred to law enforcement
agency
10
Referred for prosecution or indicted
Convicted, plead guilty, sentenced, or fined
Discharged, terminated, or contract not renewed
Staff resigned (prior to completion of investigation)
Staff resigned (after investigation was completed)
11
Other – Specify
12
No action taken
06
07
08
09
NONCONSENSUAL SEXUAL ACTS: Sexual contact of any
person without his or her consent, or of a person who is
unable to consent or refuse;
AND
Contact between the penis and the vulva or the penis
and the anus including penetration, however slight; OR
Contact between the mouth and the penis, vulva, or anus;
OR
Penetration of the anal or genital opening of another person,
however slight, by a hand, finger, object, or other instrument.
ABUSIVE SEXUAL CONTACT (less severe): Sexual
contact of any person without his or her consent, or of a
person who is unable to consent or refuse;
AND
Intentional touching, either directly or through the clothing, of
the genitalia, anus, groin, breast, inner thigh, or buttocks of
any person.
EXCLUDE incidents in which the contact was incidental to a
physical altercation.
39. At the time of the incident, how long had the
staff worked at the facility?
(Mark ( X ) all that apply for all staff involved.)
01
Less than 6 months
6 months to 1 year
02
1 to 5 years
03
5 to 10 years
04
More than 10 years
05
NOTES
SEXUAL HARASSMENT BY ANOTHER YOUTH: Repeated
and unwelcome sexual advances, requests for sexual favors, or
verbal comments, gestures, or actions of a derogatory or
offensive sexual nature by one youth directed toward another.
STAFF SEXUAL MISCONDUCT: Any behavior or act of a
sexual nature directed toward a youth by an employee,
volunteer, contractor, official visitor or other agency
representative (exclude family, friends or other visitors).
Sexual relationships of a romantic nature between staff and
youths are included in this definition. Consensual or
nonconsensual sexual acts include—
Intentional touching, either directly or through the clothing, of
the genitalia, anus, groin, breast, inner thigh, or buttocks that
is unrelated to official duties or with intent to abuse, arouse,
or gratify sexual desire;
OR
Completed, attempted, threatened, or requested sexual acts;
OR
Occurrences of indecent exposure, invasion of privacy, or
staff voyeurism for reasons unrelated to official duties or for
sexual gratification.
STAFF SEXUAL HARASSMENT: Repeated verbal
comments or gestures of a sexual nature to a youth by an
employee, volunteer, contractor, official visitor, or other
agency representative (excludes family, friends, or other
visitors). Include demeaning references to gender; or sexually
suggestive or derogatory comments about body or clothing;
OR
Repeated profane or obscene language or gestures.
Gender categories
TRANSGENDER: A person whose gender identity (i.e.,
internal sense of feeling male or female) is different from the
person’s assigned sex at birth.
INTERSEX: A person whose sexual or reproductive
anatomy or chromosomal pattern does not seem to fit
typical definitions of male or female. Intersex medical
conditions are sometimes referred to as disorders of sex
development.
FORM SSV-IJ (4-27-2017)
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| File Type | application/pdf |
| File Title | Microsoft Word - Document1 |
| Author | guerinop |
| File Modified | 2018-07-25 |
| File Created | 2011-02-10 |