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PREA Sexual Abuse, Sexual Assault, or Sexual Harassment Reporting Form
This form has been modified since it was saved. Please review all fields before submitting.
Youth Last Name
Youth First Name
Youth Middle Initial
Youth Location at Time of Incident:
-- Select One --
Juvenile Detention Center
Youth Treatment Center
Residential Treatment Placement
Ohio Department of Youth Services
Juvenile Court Probation
Youth Advocate Program
Youth Assessment Center
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
Alleged Staff Member(s) Involved:
List name(s) of staff member(s) involved.
Alleged Youth Involved:
List name(s) of youth other than victim involved.
Please Describe Suspected Abuse:
Anonymous reports will always be investigated, however, if you leave contact information, it provides us with the best opportunity to follow-up. Thank you.
Your Last Name:
Your First Name:
Your Middle Initial:
Your Phone Number:
Your Email Address:
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