PREA Sexual Abuse or Contact Checklist

Shift Commander completes each applicable line and submits all completed sections.
Section 1: Incident Information

Initial Report:



Name/Number
Date/Time

Shift Commander:



Reported by:



Staff receiving allegation:



Victim/abuser separated by:



Names of those involved in alleged abuse or contact

Name
Number
Alleged victim (V)/Alleged abuser (A) /unknown (U)














If alleged abuse involves staff use Staff Sexual Misconduct Section, Section 4.

Crime scene secured

☐ N/A ☐ Crime Scene Initiated Date/Time:

Alleged victim(s) and alleged abuser(s) are separated in safe and secure locations

☐ Completed Date/Time: Instruct them not to wash, brush teeth, change clothes, eat, drink, urinate, or defecate until
evidence is collected.When and where alleged contact occurredLocation:Date/Time:

Additional information:




Section 2: Initial Assessment Checklist

Initial Interviews completed: ☐ Yes Date/Time: Investigator:Based on initial interviews the Alleged Contact Type and next action is: (Select One)
☐ Unfounded Allegation was proved false☐ Sexual Activity, Consensual Write a DOR, Exit PREA process☐ Sexual  Harassment,
Resident-Resident Write a DOR☐ Sexual Abuse 1 Section 3, Forensic Exam, 5-day window☐ Sexual Abuse 1 or 2 Section
2 Supplement, Non-emergency☐ Sexual Harassment, Staff-Resident PCM Review☐ Staff Sexual Misconduct Section 4, Staff Sexual Misconduct
Additional Comments:
Facility Duty Notified: ☐ Yes ☐ No105 Report Sent: ☐For Sexual Activity, Consensual: Shift Commander signs and submits Sexual Contact Checklist and information reports
to:
☐ Copy to Investigations ☐ Copy to PREA Compliance Manager
Shift Commander: Date/Time:

Section 2 Supplement: SEXUAL ABUSE CASES, Non-emergency

Notify medical, or escort resident to medical.
☐ Yes
☐ N/ADate/Time:Notify mental health for support of a victim.*Follow-up required within 24 hours.☐ Yes
☐ N/ADate/Time:End of ChecklistShift commander signs and submits Sexual Abuse or Contact Checklist and information reports to:
☐ Copy to investigations
☐ Copy to PREA Compliance Manager
☐ Copy to Facility Duty Officer
☐ Copy to PREA Coordinator
☐ Staff accused ☐ Copy to Special Investigations Unit
Shift Commander: Date/Time:Review

Reviewed by:(Investigations or PREA Compliance Manager)

Signature: __________________Date________☐ Concur with finding
☐ Substantiated
☐ Unsubstantiated
☐ Unfounded
☐ Other
Review Notes:


Section 3: Emergency Response

Action Required
Comments
Initials

Victim receives emergency medical treatment
☐ N/A ☐ Completed Notifications (If not already completed)
☐ Facility Head
☐ Administrative Duty Officer (Staff Sexual Misconduct)
☐ Investigator
☐ Mental Health 

If hospital transport is needed, before transport is made, collect evidence in accordance with SOP 116.02.01.001.☐ N/A ☐ Completed  Before the transport is made,
the Shift Commander or investigator notifies the hospital, law enforcement, and victim advocate so forensic evidence can be collected.
☐ Hospital Notified
☐ Law Enforcement Notified
☐ Victim AdvocateAgency:
Investigator Name:
Contact Information:
Case #:
Send PREA Nursing Encounter form, and medical history with transport.
☐ N/A ☐ Completed Forensic exam results delivered to investigator.
☐ N/A
☐ Law enforcement
☐ Facility Investigations Medical follow-up information delivered to medical.
☐ N/A ☐ Completed Additional information:


End of Checklist

Section 4: Staff Sexual Misconduct

SOME EVIDENCE
Comments
Initial

Contact Facility Head or Facility Duty Officer to determine what level of action will be taken so staff will have no contact with the resident.
☐ Reassign to another unit
☐ Reassign to another facility☐ N/A

Contact Statewide Duty Officer
☐ Completed
☐ N/A
Staff interviews in sexual abuse cases require SIU approval.
☐ SIU accepts case
☐ SIU provides guidance
☐ N/AStaff/contractor facility removal authorized.
☐ Facility Head, Enter name
☐ Administrative Duty Officer, Enter name
☐ Completed
☐ N/A
NO EVIDENCE, except unfoundedDecision on work assignment, to separate staff or contractor and resident
☐ Duty Officer: Enter name
☐ Reassign to another unit
☐ Reassign to another facility
☐ N/AVolunteer or Visitor:
☐ Remove from the facility
☐ N/AAdditional information:

End of Checklist