Form JD-ES-293 "Prison Rape Elimination Act (Prea) Incident Report" - Connecticut

What Is Form JD-ES-293?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-ES-293 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-ES-293 "Prison Rape Elimination Act (Prea) Incident Report" - Connecticut

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PRISON RAPE ELIMINATION ACT
STATE OF CONNECTICUT
(PREA) INCIDENT REPORT
SUPERIOR COURT
JD-ES-293 Rev. 10-17
www.jud.ct.gov
42 U.S.C. § 15601, et. seq.
Instructions
See the instructions on the instructions page for where to submit this form
Use this form to report an incident or incidents of sexual abuse or
or to whom you may make a verbal report of a PREA incident. The Judicial
sexual harassment against an individual in the custody of the Judicial
Marshal Services PREA Coordinator is required to complete this report for
Branch, allegedly by either a Judicial Branch employee, contractor,
any alleged PREA incident involving an individual in the custody of Judicial
volunteer, intern or an individual in the custody of the Judicial Branch.
Marshal Services. The CSSD PREA Manager is required to complete this
This form is not required in order to report a PREA incident.
report for any alleged PREA incident involving a Juvenile in detention.
Location of incident
Incident date
Incident Time (am/pm)
Type of Incident
Sexual Abuse against an individual in the
By
Employee
Contractor
custody of the Judicial Branch
Volunteer
Intern
Individual in the custody of the Judicial Branch
Other:
Employee
Contractor
Sexual Harassment against an individual
By
in the custody of the Judicial Branch
Volunteer
Intern
Individual in the custody of the Judicial Branch
Other:
Person who received incident report
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Person against whom incident is being reported
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Alleged Victim
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Witnesses
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Description of Incident
(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.)
(Continued on page 2)
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PRISON RAPE ELIMINATION ACT
STATE OF CONNECTICUT
(PREA) INCIDENT REPORT
SUPERIOR COURT
JD-ES-293 Rev. 10-17
www.jud.ct.gov
42 U.S.C. § 15601, et. seq.
Instructions
See the instructions on the instructions page for where to submit this form
Use this form to report an incident or incidents of sexual abuse or
or to whom you may make a verbal report of a PREA incident. The Judicial
sexual harassment against an individual in the custody of the Judicial
Marshal Services PREA Coordinator is required to complete this report for
Branch, allegedly by either a Judicial Branch employee, contractor,
any alleged PREA incident involving an individual in the custody of Judicial
volunteer, intern or an individual in the custody of the Judicial Branch.
Marshal Services. The CSSD PREA Manager is required to complete this
This form is not required in order to report a PREA incident.
report for any alleged PREA incident involving a Juvenile in detention.
Location of incident
Incident date
Incident Time (am/pm)
Type of Incident
Sexual Abuse against an individual in the
By
Employee
Contractor
custody of the Judicial Branch
Volunteer
Intern
Individual in the custody of the Judicial Branch
Other:
Employee
Contractor
Sexual Harassment against an individual
By
in the custody of the Judicial Branch
Volunteer
Intern
Individual in the custody of the Judicial Branch
Other:
Person who received incident report
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Person against whom incident is being reported
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Alleged Victim
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Witnesses
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Name (Last, First, Middle initial)
Employee
Individual in custody of the Judicial Branch
Other
Address
Phone
Description of Incident
(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.)
(Continued on page 2)
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Description of Incident (Continued)
Persons Notified (as applicable)
Unit PREA Coordinator (Name)
Time (am/pm)
Date
By (Name)
Supervisor/Division Director (Name and Title)
Time (am/pm)
Date
By (Name)
Human Resources Officer (Name and Title)
Time (am/pm)
Date
By (Name)
Superintendent/Chief Judicial Marshal/Program Manager (Name and Title)
Time (am/pm)
Date
By (Name)
State or Local Police (Name, Badge, Title and Department)
Time (am/pm)
Date
By (Name)
Other (Name and Title)
Time (am/pm)
Date
By (Name)
Injuries
Injury/suspected injury
To Individual in Custody
To Employee
To Other:
Treatment/Evaluation Refused by:
Referrals Made
To Whom
Time (am/pm)
Date
By (Initials)
Hospital Name:
Transported to Hospital
Yes
No
I acknowledge that the above information is accurate and complete to the best of my knowledge and belief.
Date
Time (am/pm)
Signature
Person completing this form (Include title)
(Continued on page 3)
JD-ES-293 Rev. 10-17 — Page 2
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Statement of Witness
Facility
Location of incident
Incident date
Time (am/pm)
Statement of (Name)
Title
Description 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.)
I acknowledge that this statement is accurate and complete to the best of my knowledge and belief.
Signature of witness
Date
Time (am/pm)
(Instructions on next page)
JD-ES-293 Rev. 10-17 — Page 3
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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:
• The highest level supervisor assigned to the Judicial Branch confinement facility in which the
alleged incident occurred;
• The Judicial Branch PREA Coordinator;
• The Unit PREA Coordinator;
• The Program Manager for Equal Employment Opportunity for the Judicial Branch;
• A personnel officer, manager or director in the Administrative Services Division Human
Resource Management Unit; or
• A 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 — Instruction Page
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