Appendix 8: Sample sexual abuse incident review forms

Sexual abuse incident review checklist

Sexual abuse incident review checklist

This sample checklist can help guide the process of reviewing known incidents and reported allegations, as required by PREA. Note that PREA Standard 115.286/386 requires agencies to conduct reviews of every sexual abuse investigation. Sexual abuse incident reviews must take place within 30 days of an investigation, whether the allegation was substantiated or was not.

This sample checklist was adapted from the “Alvis House Community Corrections Center Sexual Assault Response Team (SART) Checklist.”

  1. Sexual Abuse Incident Review Checklist
  1. Date:
  1. Names of Review team members (check if present at the meeting):
    1. [NAME]
    2. [NAME]
    3. [NAME]
    4. [NAME]
    5. [NAME]
    6. [NAME]
    7. [NAME]
    8. [NAME]
  1. Summary of incident, including date and time:

RESIDENT SAFETY

  1. Did a team member respond to the victim at the time of the incident?
    1. Yes
    2. No
  2. List name of responding staff person, date and time of contact with client/victim:
    1. Reporting staff member:
    2. Date:
    3. Time:
  3. Did the client/victim require medical care?
    1. Yes
    2. No
    3. If yes, list the name and address of the medical provider, and the date and time that treatment was received.
  4. Was the client/victim informed of services offered by [insert name of rape crisis center/victim advocacy program] (such as counseling)?
    1. Yes
    2. No
  5. Did the client/victim agree to receive in-house services?
    1. Yes
    2. No
  6. Was the client/victim informed of community-based services related to his or her specific area of need?
    1. Yes
    2. No
  7. Were mental health services recommended?
    1. Yes
    2. No
    3. If yes, did the client/victim agree to receive mental health services?
      1. Yes
      2. No

POLICIES AND PROCEDURES

  1. Was the client/victim informed of confidentiality and duty to report?
    1. Yes
    2. No
  2. Was the perpetrator identified?
    1. Yes
    2. No
    3. If yes, list the name, status (resident or staff person), and facility location.
  3. Did the client/victim indicate feeling uncomfortable with any specific client or employee in the facility?
    1. Yes
    2. No
    3. If yes, list name, job title (if relevant), and facility location of all persons named by the client/victim. Also, state why the client feels uncomfortable around the named individuals.
  4. Did the facility employee(s) respond to the incident according to agency policies?
    1. Yes
    2. No
  5. Is any additional employee training recommended to improve understanding of, or response to, client sexual victimization?
    1. Yes
    2. No
    3. If yes, indicate areas in which training is recommended.

REPORTING

  1. Was the response to the client/victim timely?
    1. Yes
    2. No
    3. If no, what caused a delay in services to the client/victim?
  2. Were the client/victim’s emergency contacts notified?
    1. Yes
    2. No
  3. Was law enforcement contacted?
    1. Yes
    2. No
    3. If yes, which agency?
  4. Did law enforcement respond to the scene of the incident?
    1. Yes
    2. No
    3. N/A
  5. Was the location of the alleged sexual assault secured?
    1. Yes
    2. No
    3. N/A
  6. Was evidence removed from the scene by law enforcement?
    1. Yes
    2. No
    3. N/A
    4. If yes, list known items removed from the scene:
  7. Were documents related to this incident completed accurately?
    1. Yes
    2. No
  8. Was any pertinent information overlooked or omitted?
    1. Yes
    2. No
    3. If yes, please identify:
  9. Please list the whereabouts of the client/victim as of the date of this document. (Check all that apply.)
    1. Removed from the program
    2. Transferred to facility
    3. Client hospitalized (Name of hospital: _)
    4. Other (specify):
  10. Please list the whereabouts of the perpetrator as of the date of this document. (Check all that apply.)
    1. Transferred to facility
    2. Placed in secure custody
    3. Unknown
    4. Other (specify):

PROCESS REVIEW

  1. Did someone conduct an on-site review of the location where the incident occurred?
    1. Yes
    2. No
  2. Who conducted the review? List names and job titles.
  3. Did the review identify any physical vulnerabilities in the facility?
    1. Yes
    2. No
    3. If yes, please identify the vulnerabilities noted and planned action steps, including time lines:
  4. Are you aware of any media coverage related to this incident?
    1. Yes
    2. No
    3. If yes, list the type of media coverage:

RECOMMENDED IMPROVEMENTS

  1. Based on the incident and the agency’s response, please list any policies that should be revised. State what changes are recommended and how they would improve our response to, or prevention of, client sexual victimization at facility.
  2. Based on the incident and the agency’s response, please list any improvements to facility security where the violation occurred.
  3. Based on the incident and the agency’s response, please list any services not currently provided that may improve resident safety and protection from sexual victimization.
  4. Based on the incident and the agency’s response, could any changes be made to assist victims who disclose sexual victimization (such as designating a person to receive reports or ensuring privacy)?
  5. Will the incident be included in statistics reported to the U.S. Department of Justice? That is, was it deemed “founded”?
    1. Yes
    2. No
    3. If yes, was it deemed a “PREA incident­­”?
      1. Yes
      2. No
    4. If the answer to either question is no, why not?
  6. If the incident was founded and substantiated, did possible motives include the victim’s social or sexual identity or perceived identity, including race; ethnicity; gender identity or sexual orientation; gang membership; or other group dynamics at the facility?
    1. Yes
    2. No
    3. Explanation:
  1. Name & job title of person completing this document:
  1. PRINTED NAME
  1. JOB TITLE
  1. Signature:
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