PREA Incident Report Form

PREA Administration & Compliance Services Program

If you would like to report an incident of sexual assault, sexual abuse or sexual harassment involving a youth in any Juvenile Detention or Youth Correctional Facility, please complete the following form.

DO NOT ENTER ANY PRIVATE INFORMATION ON THIS FORM. IT IS NOT SECURE.

For security reasons, please DO NOT enter any private information such as social security numbers, medical information, or financial information/records in this form. It is not secure. If you need to make an inquiry utilizing private information, please call the appropriate number listed on the JJPO website – Contact Us.

Please note: Items with the red asterisk ‘*’ are mandatory fields.

**If you would like to be contacted, please fill in your contact information at the bottom of the form.

Name of the Youth *

Type of Incident (Check all that apply)

Details *

Facility Where Incident Occurred *

Date of the Incident (if known)

[None] Delete the Date

Reporter's Name

Reporter's Address

Reporter's Phone Number

Reporter's Email