Prison Rape Elimination Act (PREA) Report Form
Name (Reporting Party)
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Victims Name
*
First Name
Last Name
Which facility did the incident occur?
*
Please Select
Central Booking - 101 N. Kansas Ave., Olathe, KS 66061
New Century Detention Center - 27745 W. 159th St., New Century, KS 66031
Type of Incident
*
Please Select
Inmate on Inmate
Staff on Inmate
Date and Time of Incident
*
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (module/area)
Offenders
Please list the names of the offender(s) involved.
First Offender's Name
First Name
Last Name
Second Offender's Name
First Name
Last Name
Third Offender's Name
First Name
Last Name
Witnesses
Please list any persons who witnessed the incident. More can be identified in the narrative section below if necessary.
First Witness Name
First Name
Last Name
Second Witness Name
First Name
Last Name
Third Witness Name
First Name
Last Name
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Prison Rape Elimination Act (PREA) Report Form
Please explain the details of the incident including any other persons not already identified.
*
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