PREA Sexual Abuse, Sexual Assault, or Sexual Harassment Reporting Form

2. Youth Last Name*

3. Youth First Name*

4. Youth Middle Initial

6. Youth Location at Time of Incident:*
   -- Select One --Juvenile Detention CenterYouth Treatment CenterResidential Treatment PlacementGroup HomeOhio Department of Youth ServicesCommunity DetentionJuvenile Court ProbationYouth Advocate ProgramYouth Assessment CenterOther

7. Date and Time of Suspected Incident(s):
   Date and Time of Suspected Incident(s): Start Date

   Date and Time of Suspected Incident(s): Start Time

   —

   Date and Time of Suspected Incident(s): End Date

   Date and Time of Suspected Incident(s): End Time

9. Alleged Staff Member(s) Involved:

   List name(s) of staff member(s) involved.

10. Alleged Youth Involved:

    List name(s) of youth other than victim involved.

12. Please Describe Suspected Abuse:

14. Anonymous reports will always be investigated, however, if you leave contact information, it provides us with the best opportunity to follow-up. Thank you.

16. Your Last Name:

17. Your First Name:

18. Your Middle Initial:

20. Your Phone Number:

21. Your Email Address:

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field