NDCS PREA Reporting Form

Incident Information

Name of Inmate *

Facility

Please provide the name of the facility where the incident occurred, if known.

Date of Incident (If Known)

Month

Day

Year

Inmate number, if known

Type of Incident *

Sexual Assault

Sexual Abuse

Sexual Harassment

Retaliation for reporting or being involved in a PREA incident

Other PREA (explain)

Type of Incident Other PREA (explain)

Details *

If you would like to be contacted, please fill in your contact information below.

Full Name

Address

Phone Number

Email