PRISON RAPE ELIMINATION ACT (PREA) INCIDENT REPORT JD-ES-293 Rev. 10-17 42 U.S.C. 247 15601, et. seq.Instructions Use this form to report an incident or incidents of sexual abuse or sexual harassment against an individual in the custody of the Judicial Branch, allegedly by either a Judicial Branch employee, contractor, volunteer, intern or an individual in the custody of the Judicial Branch. This form is not required in order to report a PREA incident. See the instructions on the instructions page for where to submit this form or to whom you may make a verbal report of a PREA incident. The Judicial Marshal Services PREA Coordinator is required to complete this report for any alleged PREA incident involving an individual in the custody of Judicial Marshal Services. The CSSD PREA Manager is required to complete this report for any alleged PREA incident involving a Juvenile in detention. STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Incident Time (am/pm) Incident date Location of incident Other: Individual in the custody of the Judicial Branch Intern Volunteer Contractor EmployeeBy Sexual Harassment against an individual in the custody of the Judicial Branch Other: Individual in the custody of the Judicial Branch Intern Volunteer Contractor EmployeeBy Sexual Abuse against an individual in the custody of the Judicial BranchType of IncidentPerson who received incident report Phone Address Other Individual in custody of the Judicial Branch Employee Name (Last, First, Middle initial)Witnesses Phone Address Other Individual in custody of the Judicial Branch Employee Name (Last, First, Middle initial) Phone Address Other Individual in custody of the Judicial Branch Employee Name (Last, First, Middle initial) Phone Address Other Individual in custody of the Judicial Branch Employee Name (Last, First, Middle initial)Alleged Victim Phone Address Other Individual in custody of the Judicial Branch Employee Name (Last, First, Middle initial)Person against whom incident is being reported(Describe as accurately and completely as possible the events that occurred; indicate the persons involved. If injury occurred, describe the nature of the injury, its cause, and actions taken to treat the injury.)Description of Incident (Continued on page 2) American LegalNet, Inc. www.FormsWorkFlow.com Transported to Hospital Injury/suspected injuryI acknowledge that the above information is accurate and complete to the best of my knowledge and belief.JD-ES-293 Rev. 10-17 227 Page 2Persons Notified (as applicable)Injuries (Continued on page 3) Supervisor/Division Director (Name and Title) Time (am/pm) Date By (Name) By (Name) Date Time (am/pm) By (Name) Date Time (am/pm) By (Name) Date Time (am/pm) Human Resources Officer (Name and Title) Unit PREA Coordinator (Name) State or Local Police (Name, Badge, Title and Department) Time (am/pm) Date By (Initials) Signature Time (am/pm) Date Person completing this form (Include title) Treatment/Evaluation Refused by: To Other: To Employee To Individual in Custody Yes No By (Name) Date Time (am/pm) Other (Name and Title) Superintendent/Chief Judicial Marshal/Program Manager (Name and Title) Time (am/pm) Date By (Name) Hospital Name: Referrals MadeTo Whom Description of Incident (Continued) American LegalNet, Inc. www.FormsWorkFlow.com Statement of WitnessDescription of Conduct(Describe as accurately and completely as possible the events that occurred; indicate the persons involved. If injury occurred, describe the nature of the injury, its cause, and actions taken to treat the injury.) JD-ES-293 Rev. 10-17 227 Page 3 I acknowledge that this statement is accurate and complete to the best of my knowledge and belief. Facility Location of incident Incident date Time (am/pm) Statement of (Name) Title Signature of witness Date Time (am/pm) (Instructions on next page) American LegalNet, Inc. www.FormsWorkFlow.com Instructions: This process is established to meet the requirements of the Prison Rape Elimination Act (PREA), 42 U.S.C. 15601, et seq. The Judicial Branch has zero tolerance toward all forms of sexual abuse and sexual harassment in its confinement facilities. Any Judicial Branch employee may use this form to report an incident or incidents of sexual abuse or sexual harassment against an individual in the custody of the Judicial Branch, allegedly by either a Judicial Branch employee, contractor, volunteer, intern or an individual in the custody of the Judicial Branch. This form is not required in order to a report a PREA incident, except that the Judicial Marshal Services PREA Coordinator is required to complete this report for any alleged PREA incident involving an individual in the custody of Judicial Marshal Services. The CSSD PREA Manager is required to complete this report for any alleged PREA incident involving a Juvenile in detention. Such a report may be made in any manner, at any time, to any of the following individuals: 225The highest level supervisor assigned to the Judicial Branch confinement facility in which thealleged incident occurred;225The Judicial Branch PREA Coordinator;225The Unit PREA Coordinator;225The Program Manager for Equal Employment Opportunity for the Judicial Branch;225A personnel officer, manager or director in the Administrative Services Division HumanResource Management Unit; or225A supervisor, manager or division executive director.Completed incident report forms may be submitted to any of the individuals listed above. A copy of any completed form in response to an alleged violation by a Judicial Branch employee must be sent to the Judicial Branch Human Resource Management unit at: 90 Washington Street, Hartford, CT 06106. In the event that an employee makes a report without completing this form, the employee receiving the report may use the form as a guide for obtaining all relevant information from the individual making the report. When a report is received either by way of this form or in any other manner, the employee receiving the report shall begin to initiate an investigation in accordance with the Judicial Branch PREA policy and with the relevant departmental policy, if any (e.g., Judicial Marshal Services' policy; Juvenile Detention policy). JD-ES-293 Rev. 10-17 227 Instruction Page American LegalNet, Inc. www.FormsWorkFlow.com