PREA Retaliation Monitoring Form

Log the monitoring on the appropriate line (first monitoring on Line 1, second on Line 2, etc.):
No retaliation reported – write no under Code(s) for that check
Retaliation reported – write date (month/day/year) PREA Compliance Manager was notified in box. Document alleged retaliation in an incident report and forward it to the PREA Compliance
Manager.
For sexual harassment, one initial check is required to ensure no retaliation is occurring. Sexual abuse monitoring will continue over a 90-day period.
Submit the completed form to the PREA Compliance Manager after 90 days of monitoring, unless the Compliance Manager determines continued monitoring is necessary, in which case submit
the completed form once alerted by the PREA Compliance Manager that monitoring is no longer required.
Codes used to notate results of checks can include:
Resident checks: Disciplinary report (DR), Housing change (HC), Program change (Prog.), Other (O)
Staff checks: Performance review (PR), Assignment change (AC), Other (O)
The specific code can be noted, but is not required.

Name and ID # of person being monitored:



105 Report number:

Date
Staff
Code(s)
Comments

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Continue monitoring if PREA Compliance Manager determines further monitoring is necessary

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Submitted By Staff ID Number Date

Distribution:
Original – PREA Compliance Manager, PCM facility file Copy – Facility Head if possible retaliation involving residents is notedCopy – Human Resources if possible retaliation involving
staff is noted(Attach supporting documentation such as DORs, housing changes, etc.)