SSV-1-6 SSV-IA, SS Survey of Sexual Victimization

Survey of Sexual Victimization

Attachment 2 - SSV Forms

OMB: 1121-0292

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

SSV-1

FORM
(3-9-2021)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2020
Federal Bureau of Prisons
Summary Form

AND ACTING AS COLLECTION AGENT

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

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

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

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

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

What facilities are included in this data collection?
All confinement facilities operated by the Federal Bureau of
Prisons.
● INCLUDE prisons, penitentiaries, and correctional
institutions; boot camps; community correction facilities;
halfway houses; prison farms; reception, diagnostic, and
classification centers; road camps; forestry and
conservation camps; vocational training facilities; prison
hospitals; and drug and alcohol treatment facilities for
prisoners.
● EXCLUDE privately-operated facilities. (These
facilities will be contacted directly for data on
sexual victimization.)
What inmates and incidents are included in this
data collection?
Inmates under your custody between January 1, 2020, and
December 31, 2020.
● 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 October 29,
2021.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

Burden Statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB
control number. The burden of this collection is estimated to average 60 minutes per response, including reviewing instructions, searching
existing data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street,
NW, Washington, DC 20531. Do not send your completed form to this address.

Section I – INMATE–ON–INMATE SEXUAL VICTIMIZATION
DEFINITIONS

1. Does the Federal Bureau of Prisons record
allegations of inmate-on-inmate
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). Attempted
nonconsensual sexual acts are included if recorded by the
facility. (insert new sentence, bold, and dark green
background). 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
● Contact between the penis and the vulva or the penis
and the anus including penetration, however slight;

➔

Both attempted and completed

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.

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, 2020, and December 31, 2020,
how many allegations of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS were reported?
Number reported . . . . . .

None

ABUSIVE SEXUAL CONTACT

● If an allegation involved multiple victimizations,
count only once.

Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;

● 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.

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.)

● EXCLUDE incidents in which the contact was incidental
to a physical altercation.

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).

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.

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 (3-9-2021)

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
allegations of NONCONSENSUAL
SEXUAL ACTS?
01
02

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

Yes

Yes
No ➔ Skip to Item 7.

➔ Please provide an explanation in the space

below and then skip to Item 7.

5. Between January 1, 2020, and December 31, 2020,
how many allegations of inmate-on-inmate
ABUSIVE SEXUAL CONTACT were reported?
Number reported . . . . . .

➔ Do you record all reported

allegations or only substantiated
ones?
01

All

Substantiated only

➔ Please provide an explanation in the space
below and then skip to Section II.

8. Between January 1, 2020, and December 31, 2020,
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.

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

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
6a through 6d) . . . . . . . .

None

e. TOTAL (Sum of Items
9a through 9d) . . . . . . . . .

None

a. Substantiated

.......

b. Unsubstantiated

● The total should equal the number reported in
Item 8.

● The total should equal the number reported in
Item 5.

FORM SSV-1 (3-9-2021)

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:

STAFF SEXUAL MISCONDUCT

Yes

➔

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

All

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, 2020, and December 31,
2020, how many allegations of STAFF SEXUAL
MISCONDUCT were reported?

OR
● Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reasons unrelated to official duties
or for sexual gratification.

Number reported

......

None

● If an allegation involved multiple victimizations,
count only once.

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 (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 (3-9-2021)

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
separately from allegations of STAFF
SEXUAL MISCONDUCT?
01

Yes

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

➔

➔ Skip to Item 16.

➔ 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, 2020, and
December 31, 2020, 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

....

None

.........

None

d. Investigation ongoing .

None

e. TOTAL (Sum of Items
15a through 15d) . . . . . .

None

b. Unsubstantiated

c. Unfounded

● The total should equal the number reported in
Item 14.

FORM SSV-1 (3-9-2021)

Page 5

None

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

SSV-2

FORM
(3-9-2021)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2020
State Prison Systems
Summary Form

AND ACTING AS COLLECTION AGENT

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

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

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

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

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

What facilities are included in this data collection?
All State-operated confinement facilities that are intended for
adults but sometimes hold juveniles.
● INCLUDE prisons, penitentiaries, and correctional
institutions; boot camps; community correction facilities;
halfway houses; prison farms; reception, diagnostic, and
classification centers; road camps; forestry and
conservation camps; vocational training facilities; prison
hospitals; and drug and alcohol treatment facilities for
prisoners.
● INCLUDE State-operated local detention facilities in
Alaska, Connecticut, Delaware, Hawaii, Rhode Island,
and Vermont.
● EXCLUDE privately operated facilities and
facilities operated and administered by local
governments. (These facilities will be
contacted directly for data on sexual
victimization.)
● EXCLUDE facilities that hold only juveniles. (These
facilities will be contacted directly for data on sexual
victimization.)
What inmates and incidents are included in this
data collection?
Inmates under your custody between January 1, 2020, and
December 31, 2020.
● 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 greta.b.clark@census.gov
● Please return your completed summary and
substantiated incident forms by October 29,
2021.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

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

Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB
control number. The burden of this collection is estimated to average 60 minutes per response, including reviewing instructions, searching
existing data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street,
NW, Washington, DC 20531. Do not send your completed form to this address.

Section I – INMATE–ON–INMATE SEXUAL VICTIMIZATION 1. Does your State prison system record
allegations of inmate-on-inmate
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). Attempted
nonconsensual sexual acts are included if recorded by the
02
Substantiated only
facility. (insert new sentence, bold, and dark green
background). For purposes of SSV, sexual abuse is
b. Do you record attempted
disaggregated into three categories of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS
sexual victimization. These categories are:
or only completed ones?
NONCONSENSUAL SEXUAL ACTS
Both attempted and completed
01
Sexual contact of any person without his or her consent,
02
Completed only
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;

➔

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.

2. Between January 1, 2020, and December 31, 2020,
how many allegations of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS were reported?

ABUSIVE SEXUAL CONTACT

Number reported . . . . . .
None
● If an allegation involved multiple victimizations,
count only once.

Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;

● Exclude any allegations that were reported as
consensual.

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 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.

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-2 (3-9-2021)

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
allegations of NONCONSENSUAL
SEXUAL ACTS?
01
02

Yes

➔ Do you record all reported

allegations or only substantiated
ones?

Yes
No ➔ Skip to Item 7.

➔ Please provide an explanation in the space

below and then skip to Item 7.

5. Between January 1, 2020, and December 31, 2020,
how many allegations of inmate-on-inmate
ABUSIVE SEXUAL CONTACT were reported?

➔

All

Substantiated only

Please provide an explanation in the space
below and then skip to Section II.

8. Between January 1, 2020, and December 31, 2020,
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.

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.)

None

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

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

.........

● The total should equal the number reported in
Item 8.

● The total should equal the number reported in
Item 5.

FORM SSV-2 (3-9-2021)

.......

None

a. Substantiated . . . . . . .

Page 3

SECTION II – STAFF-ON-INMATE SEXUAL ABUSE
DEFINITIONS

10. Does your State prison system record
allegations of STAFF SEXUAL
MISCONDUCT?

STAFF SEXUAL MISCONDUCT

Yes

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

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, 2020, and
December 31, 2020, 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 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 (3-9-2021)

Page 4

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

Yes

➔

Section III – PRIVATE AND LOCAL ALLEGATIONS

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

Yes

➔ 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

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.

Yes

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, 2020, and
December 31, 2020, 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 (3-9-2021)

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 xx/xx/xxxx
U.S. DEPARTMENT OF JUSTICE

SSV-3

FORM
(3-5-2021)

SURVEY OF SEXUAL VICTIMIZATION, 2020
Local Jail Jurisdictions
Summary Form

BUREAU OF JUSTICE STATISTICS

AND ACTING AS COLLECTION AGENT

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

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

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

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

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

What facilities are included in this data collection?

Reporting instructions:
●

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

Please complete the entire SSV-3 Form.

●

● INCLUDE all jails and city/county correctional centers
that hold inmates beyond arraignment. Report on ALL
inmates, including those held in separate holding or
lockup areas within your facility.
● INCLUDE multi-jurisdictional facilities (e.g., regional jails).
● INCLUDE special jail facilities (e.g., medical/treatment/
release centers, halfway houses, and work farms).
● EXCLUDE privately-operated jails. (These
facilities will be contacted directly for data on
sexual victimization.)
What inmates and incidents are included in this
data collection?
Inmates under your custody between January 1, 2020, and
December 31, 2020.
● 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.

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
October 29, 2021.
● You may complete these forms online at:
https://ssv.census.gov/
●

•

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

Burden Statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB
control number. The burden of this collection is estimated to average 30 minutes per response, including reviewing instructions, searching
existing data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street,
NW, Washington, DC 20531. Do not send your completed form to this address.

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).
Attempted nonconsensual sexual acts are included if
recorded by the facility. 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, 2020?
● INCLUDE persons on transfer to treatment facilities
but who remain under your jurisdiction.
● INCLUDE persons out to court while under your
jurisdiction.
● INCLUDE persons held for other jurisdictions.

NONCONSENSUAL SEXUAL ACTS

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

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 jail (e.g.,
electronic monitoring, house arrest, community
service, day reporting, work programs).
Male
Inmates on
December 31, 2020

OR
● Contact between the mouth and the penis, vulva, or
anus;

Female

OR
● Penetration of the anal or genital opening of another
person, however slight, by a hand, finger, object, or other
instrument.

b. ADMITTED to your jail facilities during 2020?

ABUSIVE SEXUAL CONTACT

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

Female

New admissions
during 2020 . . . . . . . . .

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, 2020, and
December 31, 2020, 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, 2020, through December 31, 2020, and
divide the result by 365.
Male

Female

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

FORM SSV-3 (3-5-2021)

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

➔ Can these be counted separately from
allegations of NONCONSENSUAL
SEXUAL ACTS?

All

Substantiated only

b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS or
only completed ones?

Yes

Both attempted and completed

Completed only

➔

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, 2020, and December 31, 2020,
how many allegations of inmate-on-inmate
NONCONSENSUAL SEXUAL ACTS were reported?

7. Between January 1, 2020, and December 31, 2020,
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.
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

......

.......

.....

None

..........

None

b. Unsubstantiated

None
c. Unfounded

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

d. Investigation ongoing
c. Unfounded . . . . . . . . . . .

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 (3-5-2021)

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

None

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

Yes

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?

➔

All

Substantiated only

Please provide an explanation in the space
below and then skip to Section III.

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—

STAFF SEXUAL HARASSMENT

.....

None

..........

None

● Demeaning references to gender; or sexually suggestive
or derogatory comments about body or clothing;

.......

b. Unsubstantiated

d. Investigation ongoing

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 (3-5-2021)

● Occurrences of indecent exposure, invasion of
privacy, or staff voyeurism for reasons unrelated to
official duties or for sexual gratification.

None

a. Substantiated

c. Unfounded

● 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;

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

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

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

All

Yes

Substantiated only

No ➔ Skip to Item 18.

➔ Please provide an explanation in the space

13. Between January 1, 2020, and
December 31, 2020, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
Number reported

......

➔ Please provide an explanation in the space

16. Between January 1, 2020, and
December 31, 2020, 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 13, how
many were — (Please contact the agency or
office responsible for investigating allegations of
sexual victimization in order to fully complete this
form.)

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

..........

None

c. Unfounded

None

d. Investigation ongoing

None

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

None

c. Unfounded

d. Investigation ongoing

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

FORM SSV-3 (3-5-2021)

.........

● 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 (3-5-2021)

Page 6

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

SSV-4

FORM
(3-5-2021)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2020
Other Correctional Facilities
Summary Form

AND ACTING AS COLLECTION AGENT

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

DATA SUPPLIED BY
Title

TELEPHONE
E-MAIL
ADDRESS

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

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

▼▼▼

Name

Area Code

ZIP Code
Number

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

What facilities are included in this data collection?

•

•
•
•
•
•

PRIVATELY OPERATED FACILITIES: All privately
owned or operated confinement facilities including prisons,
jails, detention centers, community-based facilities, and other
correctional facilities that are intended for adults but
sometimes hold juveniles. INCLUDE privately operated
multi-jurisdictional facilities.
FACILITIES OPERATED BY OR FOR:

THE BUREAU OF IMMIGRATION AND
CUSTOMS ENFORCEMENT

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

Inmates under your custody between January 1, 2020, and
December 31, 2020.

•

•
•
•
•
•

THE UNITED STATES MILITARY

What inmates and incidents are included in this data
collection?

•

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.

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

Returning forms:
If you need assistance, please call the U.S. Census
Bureau toll–free at 1–888–369–3613, option 2,
or e-mail govs.ssv@census.gov
Please return your completed summary and
substantiated incident forms by
October 29, 2021.
You may complete these forms online at:
https://ssv.census.gov/

EXCLUDE inmates held in other jurisdictions.

•
•
•
•
•

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 out to court while 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). Attempted
nonconsensual sexual acts are included if recorded by the
facility. For purposes of SSV, sexual abuse is disaggregated
into three categories of inmate-on-inmate sexual victimization.
These categories are:

● INCLUDE persons held for other jurisdictions.

NONCONSENSUAL SEXUAL ACTS

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

Sexual contact of any person without his or her consent,
or of a person who is unable to consent or refuse;

a. CONFINED on December 31, 2020?
● INCLUDE persons on transfer to treatment
facilities but who remain under your jurisdiction.

● 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

AND
● Contact between the penis and the vulva or the penis
and the anus including penetration, however slight;

Female

OR
● Contact between the mouth and the penis, vulva, or
anus;

Inmates on
December 31, 2020

b. ADMITTED to your facility during 2020?

● Penetration of the anal or genital opening of another
person however slight, by a hand, finger, object, or other
instrument.

● 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

● 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.

Female

New admissions
during 2020 . . . . . . .

● EXCLUDE incidents in which the contact was incidental
to a physical altercation.

2. Between January 1, 2020, and
December 31, 2020, 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, 2020, through December 31, 2020, and
divide the result by 365.
Male

Female

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

FORM SSV-4 (4-16-2020)

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 facility record allegations of inmate-oninmate NONCONSENSUAL SEXUAL ACTS? (See
definitions on page 2.)
Yes

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,

All

Substantiated only

b. Do you record attempted
NONCONSENSUAL SEXUAL ACTS
or only completed ones?

Yes

or only substantiated ones?

Both attempted and completed

Completed only

➔ Can these be counted separately from
allegations of NONCONSENSUAL
SEXUAL ACTS?
01

Yes

➔ 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, 2020, and
December 31, 2020, how many allegations
of inmate- on-inmate ABUSIVE SEXUAL
CONTACT were reported?

4. Between January 1, 2020, and
December 31, 2020, 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

● 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

● 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) . . . . . . . .

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

None

● The total should equal the number reported in Item 4.
FORM SSV-4 (3-5-2021)

Page 3

9. Does your facility record allegations of inmate-oninmate SEXUAL HARASSMENT? (See definitions on
page 2.)
01

Yes

➔ Do you record all reported
All

Substantiated only

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:

allegations or only substantiated
ones?
01

Section III – STAFF-ON-INMATE SEXUAL ABUSE

➔ 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
● Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reason unrelated to official duties
or for sexual gratification.

10. Between January 1, 2020, and
December 31, 2020, how many allegations of
inmate-on-inmate SEXUAL HARASSMENT
were reported?

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 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 (3-5-2021)

Page 4

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

Yes

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

➔ Do you record all reported

occurrences, or only substantiated
ones?

Yes

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

All

Yes

Substantiated only

No ➔ Skip to Item 18.

➔ Please provide an explanation in the space

below and then skip to Item 15.

13. Between January 1, 2020, and
December 31, 2020, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?
Number reported . . . . . .

➔ Please provide an explanation in the space
below and skip to Item 18.

16. Between January 1, 2020, and
December 31, 2020, 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

b. Unsubstantiated

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

None

c. Unfounded

d. Investigation ongoing .

None

d. Investigation ongoing

e. TOTAL (Sum of Items 14a
through 14d) . . . . . . . . . .

None

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

a. Substantiated

.......

b. Unsubstantiated

● The total should equal the number reported in Item 13.

FORM SSV-4 (3-5-2021)

Page 5

.......

None

.....

None

..........

None

● 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 (3-5-2021)

Page 6

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

SSV-5

FORM
(3-8-2021)

BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2020
State Juvenile Systems
Summary Form

AND ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

U.S. CENSUS BUREAU

DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

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

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

Title

▼▼▼

Name

Area Code

ZIP Code
Number

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

What facilities are included in this data collection?
All State-operated juvenile residential placement facilities
used to house juveniles and youthful offenders, regardless of
age or reason for placement.
● INCLUDE State-operated juvenile residential facilities
such as: detention centers, training schools, long-term
secure facilities; reception or diagnostic centers; group
homes or halfway houses; boot camps; ranches; forestry
camps, wilderness or marine programs, or farms;
runaway or homeless shelters; and residential treatment
centers for juveniles.
● EXCLUDE privately operated facilities and
facilities operated or administered by local
governments. (These facilities will be
contacted directly for data on sexual
victimization.)
What persons and incidents are included in this
data collection?
Juveniles and youthful offenders, regardless of age or reason
for placement, under your custody between January 1, 2020,
and December 31, 2020.
● 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 the U.S. Census
Bureau toll-free at 1–800–253–2078 or email
greta.b.clark@census.gov
● Please return your completed summary and
substantiated incident forms by
October 29, 2021.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

2. On December 31, 2020, 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, 2020.

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, 2020, 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, 2020.

1. On December 31, 2020, 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, 2020, and December 31, 2020,
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 (3-8-2021)

Page 2

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

allegations of youth-on-youth NONCONSENSUAL
SEXUAL ACTS?
01
Yes ➔ a. Do you record all reported
occurrences, or only
substantiated ones?

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). Attempted
nonconsensual sexual acts are included if recorded by the
facility. For purposes of SSV, sexual abuse is disaggregated
into three categories of youth-on-youth sexual victimization.
These categories are:

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;

AND
● Contact between the penis and the vulva or the penis
and the anus, including penetration, however slight;
OR

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.

6. Between January 1, 2020, and December 31, 2020,
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
● 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
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.
7. Of the allegations reported in Item 6, how
many were — (Please contact the agency or office
responsible for investigating allegations of sexual
victimization in order to fully complete this form.)
a. Substantiated . . . . . . . .

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
occured.
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
7a through 7d) . . . . . . . . . . .

None

● The total should equal the number reported in
Item 6.
FORM SSV-5 (3-8-2021)

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

Yes

from allegations of
NONCONSENSUAL SEXUAL ACTS?
01

Yes

➔ Skip to Item 11.
02

Yes

➔ Can these be counted separately

➔ Please provide an explanation in the space

➔ Do you record all reported allegations
or only substantiated ones?
01

All

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, 2020, and
December 31, 2020, how many allegations
of youth-on-youth ABUSIVE SEXUAL
CONTACT were reported?

12. Between January 1, 2020, and
December 31, 2020, 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.)

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 . .

None

e. TOTAL (Sum of Items
10a through 10d) . . . . . . . . . .

None

e. TOTAL (Sum of Items
13a through 13d) . . . . . . .

None

● The total should equal the number reported in
Item 9.

FORM SSV-5 (3-8-2021)

● 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

Yes

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

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, 2020, and
December 31, 2020, 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.)

● 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

● Repeated profane or obscene language or gestures.

● The total should equal the number reported in
Item 15.

FORM SSV-5 (3-8-2021)

Page 5

17. Does your State juvenile system record
allegations of STAFF SEXUAL HARASSMENT?
(See definitions on page 5.)
01

Yes

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

➔ Skip to Item 20.

Yes

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.

Yes

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, 2020, and
December 31, 2020, 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

NOTES

● The total should equal the number reported in
Item 18.

FORM SSV-5 (3-8-2021)

None

Page 6

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

SSV-6

FORM
(3-8-2021)

SURVEY OF SEXUAL VICTIMIZATION, 2020
Locally or Privately-Operated Juvenile Facilities

BUREAU OF JUSTICE STATISTICS

AND ACTING AS COLLECTION AGENT

Summary Form
DATA SUPPLIED BY

TELEPHONE
E-MAIL
ADDRESS

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

City

Area code

FAX
NUMBER

Number

State

▼

OFFICIAL
ADDRESS

U.S. CENSUS BUREAU

Title

▼▼▼

Name

U.S. DEPT. OF COMMERCE

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, 2020, and December 31, 2020.
● INCLUDE incidents involving juveniles or youthful
offenders under the authority, custody, or care of your
confinement or community-based facilities or staff.
● EXCLUDE incidents involving juveniles or
youthful offenders held in facilities operated
by your State juvenile system.

● If you need assistance, please call the U.S. Census
Bureau toll–free at 1–888–369–3613, option 2, or
e-mail govs.ssv@census.gov
● Please return your completed summary and
substantiated incident forms by
October 29, 2021.
● You may complete these forms online at:
https://ssv.census.gov/
● MAIL TO: U.S. Census Bureau, P.O. Box 5000,
Jeffersonville, IN 47199-5000
● FAX (TOLL FREE): 1–888–262–3974

Burden Statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB
control number. The burden of this collection is estimated to average 30 minutes per response, including reviewing instructions, searching
existing data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street,
NW, Washington, DC 20531. Do not send your completed form to this address.

DEFINITIONS

3. On December 31, 2020, 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, 2020.

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, 2020, 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

Native American Tribal Government

State

County

Local or municipal government

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, 2020.
5. Between January 1, 2020, and
December 31, 2020, how many persons were
admitted to or discharged from this facility?

a. TOTAL number admitted . . . . .

2. Is this facility operated by a
01

Private agency

Native American Tribal Government

State

County

Local or municipal government

Other Specify

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

FORM SSV-6 (3-8-2021)

Page 2

Section II – YOUTH-ON-YOUTH SEXUAL VICTIMIZATION
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). Attempted
nonconsensual sexual acts are included if
recorded by the facility. For purposes of SSV, sexual
abuse is disaggregated into three categories of
youth-on-youth sexual victimization. These categories are:

6. Does your facility record allegations of
youth-on-youth NONCONSENSUAL SEXUAL
ACTS?
01
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;

02
02

AND

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.

● 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.

7. Between January 1, 2020 and December 31, 2020,
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 . . . . . . . .

● If an allegation involved multiple victimizations, count only
once.

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.)

SEXUAL HARASSMENT
a. Substantiated . . . . . . . . .

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

● 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.
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
8a through 8d) . . . . . . . . . .

None

● The total should equal the number reported in Item 7.
FORM SSV-6 (3-8-2021)

Page 3

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

Yes

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

➔ Can these be counted separately

from allegations of
NONCONSENSUAL SEXUAL ACTS?
01

Yes

➔ Skip to Item 12.

➔ Please provide an explanation in the space

below and then skip to Item 12.

10. Between January 1, 2020, and
December 31, 2020, how many allegations of
youth-on-youth ABUSIVE SEXUAL CONTACT
were reported?
Number reported . . . . . . .

➔ Do you record all reported

allegations or only substantiated
ones?
01

All

Substantiated only

➔ Please provide an explanation in the space
below and then skip to Section III.

13. Between January 1, 2020, and
December 31, 2020, how many allegations of
youth-on-youth SEXUAL HARASSMENT were
reported?
Number reported . . . . . . . .

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.

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 . . . .

None

e. TOTAL (Sum of Items
11a through 11d) . . . . . . . . .

None

e. TOTAL (Sum of Items
14a through 14d) . . . . . . . . .

None

● The total should equal the number reported in Item 10.

FORM SSV-6 (3-8-2021)

● 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

STAFF SEXUAL MISCONDUCT

➔ Do you record all reported

occurrences, or only substantiated
ones?
01

All

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
● Occurrences of indecent exposure, invasion of privacy,
or staff voyeurism for reasons unrelated to official duties
or for sexual gratification.

16. Between January 1, 2020, and
December 31, 2020, how many allegations of
STAFF SEXUAL MISCONDUCT were reported?

Number reported . . . . . . . .

● If an allegation involved multiple victimizations, count only
once.

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 (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 . . . . . . . . .

None

b. Unsubstantiated . . . . . . .

None

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

None

d. Investigation ongoing . . .

None

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

None

● Repeated profane or obscene language or gestures.

● The total should equal the number reported in Item 16.

FORM SSV-6 (3-8-2021)

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

➔ 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

➔ 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, 2020, and
December 31, 2020, 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 (3-8-2021)

Page 6

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

SSV-IA

FORM
(3-8-2021)

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2020

and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

Substantiated Incident Form (Adult)

U.S. CENSUS BUREAU

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)

In the perpetrator’s cell or room
In a dormitory or other multiple housing unit
In a common area (e.g., shower, dayroom, bathroom)
In a temporary holding cell or intake area within the
facility
In a program service area (e.g., commissary, kitchen,
storage, laundry, cafeteria, workshop, hallway)
In an instructional area (e.g., classroom, school, library,
conference room)

03
04
05
06
07
08

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

09
10

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

Offsite or while in transit

Other – Specify

Location unknown

02
03

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)
04
Overnight (midnight to 6 a.m.)
05
Time unknown

Male

Transgender

Female

Intersex

8. Victim #1: What was the victim’s age at the
time of the incident?
01
02
03
04

Under age 18
18–24
25–29
30–34

05
06
07
08

35–39
40–44
45–54
55 or older

9. Victim #1: What was the victim’s race/ethnic origin?
(Mark ( X ) all that apply.)
01
02
03
04
05
06
07

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

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

Male

Transgender

Female

Intersex

11. Victim #2: What was the victim’s age at the
time of the incident?
05
35–39
01
Under age 18
06
40–44
02
18–24
03
25–29
07
45–54
04
30–34
08
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

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
02
Another inmate (non-victim)
03
Victim’s family or friend
04
Correctional officer or front line staff
05
Administrative staff
06
Medical, healthcare, or mental health staff
07
Instructor, teacher, or counselor
08
Other staff (e.g., kitchen worker, maintenance staff)
09
Chaplain or other religion official
10
Perpetrator
11
Perpetrator’s family or friend
12
Grievance coordinator, grievance process, or
ombudsperson
13
Attorney or legal guardian (e.g., other than family member)
14
Confidential informant, anonymous tip, hot line, or
through monitoring (e.g., camera, telephone, or mail)
15
Other – Specify

Page 2

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

Placed in camera room, under closer surveillance,
or increased supervision
Other – Specify

None of the above

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 (3-8-2021)

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.)

Male

Transgender

Female

Intersex

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

05
06
07
08

21. Perpetrator #1: What was the inmate
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

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
05

Bribery or blackmail
Gave victim drugs or alcohol

Offered protection from other inmates

Threatened with physical harm
Physically held victim down or restrained in
some way
Physically harmed or injured
Threatened with a weapon
Other – Specify

None

22. Perpetrator #2: What was the inmate
perpetrator’s sex or gender identity?
(See definitions on page 5.)
01

Male

Transgender

Female

Intersex

08
09
10

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

45–54
55 or older

24. Perpetrator #2: What was the inmate
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

FORM SSV-IA (3-8-2021)

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

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.)
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 inmate
Sexual relationship between inmate 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

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

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

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

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 (3-8-2021)

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

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

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
02
6 months to 1 year
03
1 to 5 years
04
5 to 10 years
05
More than 10 years

NOTES

Deﬁnitions
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 (exclude 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 (3-8-2021)

Page 5

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

SSV-IJ

FORM
(3-8-2021)

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS

SURVEY OF SEXUAL VICTIMIZATION, 2020

and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

Substantiated Incident Form (Juvenile)

U.S. CENSUS BUREAU

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

01
02

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

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)
In the perpetrator’s cell or room
In a dormitory or other multiple housing unit
In a common area (e.g., shower, dayroom, bathroom)
In a temporary holding cell or admissions area within the
facility
In a program service area (e.g., commissary, kitchen,
storage, laundry, cafeteria, workshop, hallway)
In an instructional area (e.g., classroom, school, library,
conference room)
In a recreation area (e.g., yard, courtyard, gymnasium)
In a medical area (e.g., Infirmary, health clinic)
In a staff area (office, break room, counselor’s office)
Offsite or while in transit
Other – Specify

Location unknown

02
03
04
05
06
07
08
09
10
11

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

Male
Female

03
04

Transgender
Intersex

8. Victim #1: 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

9. Victim #1: What was the victim’s race/ethnic origin?
(Mark ( X ) all that apply.)
White (not of Hispanic origin)
01
Black (not of Hispanic origin)
02
Hispanic or Latino
03
04
American Indian/Alaska Native (not of Hispanic origin)
05
Asian (not of Hispanic origin)
06
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
Other racial category in your information system –
07
Specify

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

13. Did the victim(s) sustain any physical injury
during the incident?
02
01

treatment for these injuries?
01
Yes
02
No

15. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
Given a medical examination
02
Administered a rape kit
03
Tested for HIV/AIDS
04
Tested for other sexually transmitted diseases
05
Provided with counseling or mental health
treatment
06
Offered but declined testing or treatment
07
Already released/discharged
08
None of the above
16. After the incident was reported, was the
victim(s) – (Mark ( X ) all that apply for all victims.)
01
Placed in or returned to administrative segregation,
protective custody, or disciplinary segregation
02
Placed in a medical unit, ward, or hospital
03
Confined to own cell or room
04
Given a higher custody level/different unit within
the facility
05
Transferred to another facility
06
Transferred to another housing unit or dorm, or
given a single room or cell
07
Separated from perpetrator
08
Issued disciplinary report or loss of privileges
09
Placed in camera room, under closer surveillance,
or increased supervision
10
Other – Specify

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

14. Who reported the incident?
(Mark ( X ) all that apply.)
01
Victim
02
Another youth (non-victim)
03
Victim’s family or friend
04
Correctional officer or front line staff
05
Administrative staff
06
Medical, healthcare, or mental health staff
07
Instructor, teacher, or counselor
08
Other staff (e.g., kitchen worker, maintenance staff)
09
Chaplain or other religious official
10
Perpetrator
11
Perpetrator’s family or friend
12
Grievance coordinator, grievance process, or
Section A – YOUTH-ON-YOUTH SEXUAL VICTIMIZATION
ombudsperson
➞ If the perpetrator was a staff member, go
13
Attorney or legal guardian (e.g., other than family
to Section B on pages 4–5.
member)
18. How many youth perpetrators were involved in
14
Confidential informant, anonymous tip, hot line, or through
the incident?
monitoring (e.g., camera, telephone, or mail)
15
Other – Specify
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 (3-8-2021)

19. Perpetrator #1: What was the youth perpetrator’s
25. What was the nature of the incident?
sex or gender identity? (See definitions on page 5.)
(Mark ( X ) all that apply.)
03
Transgender
01
Male
02 X Sexual harassment
04
Intersex
02
Female
03
Indecent exposure, masturbation, or voyeurism
04
20. Perpetrator #1: What was the youth perpetrator’s
Horseplay
age at the time of the incident?
Repeated and unwelcome sexual advances or
05
requests for sexual favors
04
18–19
01
Under age 13
06
Unwanted touching for sexual gratification or
05
20–24
02
13–15
abusive sexual contact
06
25 or older
03
16–17
Pressure or coercion (without force) resulting
07
in a nonconsensual sexual act
21. Perpetrator #1: What was the youth perpetrator’s
08
Physical force (or the threat of force) resulting
race/ethnic origin? (Mark ( X ) all that apply.)
in a nonconsensual sexual act
Other – Specify
09
01
White (not of Hispanic origin)
02
Black (not of Hispanic origin)
03
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic
04
origin)
26. What type of pressure or physical force was
05
Asian (not of Hispanic origin)
used by the youth perpetrator on the victim?
06
Native Hawaiian or Other Pacific Islander
(Mark ( X ) all that apply for all perpetrators.)
(not of Hispanic Origin)
01 X Sexual harassment, sexual innuendo, or
07
Other racial category in your information system –
verbal comments
Specify
Persuasion or talked into sexual activity
02
03
Surprised the victim with unwanted touching,
grabbing or groping, or victim was asleep
22. Perpetrator #2: What was the youth perpetrator’s
04
Bribery or blackmail
sex or gender identity? (See definitions on page 5.)
05
Gave victim drugs or alcohol
03
Transgender
01
Male
06
Offered protection from other youth
04
Intersex
02
Female
07
Threatened with physical harm
Physically held victim down or restrained in
08
23. Perpetrator #2: What was the youth perpetrator’s
some way
age at the time of the incident?
09
Physically
harmed or injured
01
Under age 13
04
18–19
Threatened
with a weapon
10
05
20–24
02
13–15
11
Other
–
Specify
03
16–17
06
25 or older
24. Perpetrator #2: 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

FORM SSV-IJ (3-8-2021)

None

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
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

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

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

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

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.)

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

02
03
04

06
07

FORM SSV-IJ (3-8-2021)

38. What sanction was imposed on the staff?
(Mark ( X ) all that apply for all staff involved.)
01
02
03
04
05

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

No action taken

06
07
08
09

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 (exclude 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 (3-8-2021)

Page 5

File Type	application/pdf
Author	Mueller, Stephanie (OJP)
File Modified	2021-06-24
File Created	2021-06-23