PREA Reporting To Resident Form

(The report to the resident is verbal; however, this form is needed for documentation and must be retained. Also, use this form for reporting status updates.)
Resident’s full name: Enter name.
Resident’s IDOC #: Enter number.
Facility: Choose Facility.
Incident date (if known): Select date.
☐ Choose agency Complete if city, county, or other agency was selected: Enter city, county, or agency
Date of reporting: Select date. Initial: 
Outcome:
☐ Choose an item. Initial:
Substantiated – Investigated and determined to have occurred.
Unfounded – Investigated and determined not to have occurred.
Unsubstantiated – Investigation produced insufficient evidence to make a final determination as to whether or not the event occurred.

Check all that apply:
☐ Staff member is no longer posted in the resident’s unit. Date: Select date. Initial:
☐ Staff member is no longer employed at the facility. Date: Select date. Initial:
☐ The abuser has been charged with the crime of: Date: Select date. Initial:
☐ The abuser has been convicted of the crime of: Date: Select date. Initial:
☐ Other: Enter information Date: Select date. Initial:
**Print Document**

Print name Signature

Date