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2. Name(s) of Inmate(s) Victim(s)
4. Inmate(s) Victim(s) PID
6. Name(s) of Alleged Perpetrator(s)
8. Name(s) of Witness(es)
10. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident
11. Did this incident occur inside the detention center?

    1. Yes
    2. No
    3. I don't know
13. Location where incident occured (i.e., in cell, courtyard, etc.)
15. Additional Information
19. Your Information (Optional)
21. First Name (optional)
22. Last Name (optional)
24. Address1
26. Address2
28. City
29. State
30. Zip
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

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