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2. Anonymous PREA Reporting
   All information submitted are anonymous unless you submit your contact information at the bottom of this form. Providing false or misleading information is a violation of Federal Law and may be subject to prosecution under Title 18 USC 1001. All information is subject to review and verification.
4. Name of Victim*
   Please enter the victim's name.
5. Inmate (victim) Booking Number*
   Please enter the booking number of the victim.
7. Name of Alleged Perpetrator(s)*
   Please enter the name(s) of the alleged perpetrator(s).
8. Name(s) of Witness(es)*
   Please enter the witness names. Include other names they may go by.
10. Incident Date*
    Incident Date
    Please enter the date of the incident you wish to report.
11. Incident Time*
    Incident Time
    Please enter the time the incident occurred.
13. Did the incident occur inside the jail?*

    Please select yes or no.

    1. Yes
    2. No
14. Location*
    Please enter the specific location of the incident.
16. Any Additional Relevant Information
    Please provide any additional relevant information.
18. Contact (Optional)
    Please enter your information if you would like to be contacted confidentially by an investigator about your submission.
20. Name
21. Email Address
23. Phone Number
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

* indicates a required field