Tennessee



|[pic] |Tennessee Department of Children’s Services |

| |Prison Rape Elimination Act (PREA) Risk Assessment |

Demographic Information Results

|Youth’s Name: |      | |Yes |No | |

|TFACTS ID#: |      |Race: |      |DOB: |      |

|Program Entry Date: |      | | | |Violent Aggressive |

|Date of Assessment: |      | | | |High Risk for Housing? |

|Screener’s Name: |      | | | |High Risk for Roommate? |

|Supervisor Approval Date: |      |

High Risk Information Shared?

| | | |Direct Care Staff |

| | | |Used for Housing Decisions |

| | | |Shared with Treatment Staff |

Youth Interview:

|Gender Identity: | Male | Female | Transgender | Non-Binary (does not identify as male or female) |

|Sexual Orientation: | Straight | Gay | Lesbian | Bisexual | Other |

1. Age of Youth:

|16-19 |Score 0 |      | | |

|13-15 |Score 1 |      | | |

|11-12 |Score 2 |      | | |

|10 or younger |Score 3 |      | |Question 1: |

2. Past Experience: ask “Have you ever been in a juvenile facility?”

|No |Score 2 |      | | |

|Yes |Score 0 |      | |Question 2: |

Does the youth’s response match collateral information? Yes, go to question 3 No go to question 2a.

2a. Provide relevant information below, include details if the score changed.

|      |

3. Social Skills: ask “How do you feel being in a facility with so many other juvenile justice youths?”

| |Yes |No | |

|Then ask: |Score 0 |Score 1 | |

|Do you feel you get along well with other people? |      |      | |

|Do you find it easy to make friends? |      |      | |

|Do you feel OK about being in groups of people you don’t know well? |      |      |Question 3: |

4. Perception of Risk: ask “Do you feel at risk from attack or abuse from other youths?”

(Example: have you received threats, insults and harassment from other youth, prompt with options if necessary)

|Not at all |Score 0 |      | | |

|Sometimes |Score 1 |      | | |

|Often |Score 2 |      | |Question 4: |

If sometimes or often, ask for more details and note youth’s statements below:

|      |

Does the youth’s response match collateral information? Yes, go to question 5 No go to question 4a.

4a. Provide relevant information below, include details if the score changed.

|      |

5. History of Victimization: ask “Have you ever been attacked, bullied or abused by people your own age

(your peers)?” Prompt with options if necessary.

|Never |Score 0 |      | | |

|A few times |Score 2 |      | | |

|Often |Score 4 |      | |Question 5: |

Does the youth’s response match collateral information? A few times/often, go to question 5b.

No, go to question 5a.

5a. Provide relevant information below, include details if the score changed.

|      |

5b. Ask “Have you ever had a sexual experience that you did not want to have?

If yes, ask if this information was reported to child protective services and/or law enforcement. If youth reports abuse,

follow agency reporting procedures.

|No |Score 0 |      | | |

|Yes |Score 4 |      | |Question5b: |

Does the youth’s response match collateral information? Yes, go to question 6 No, go to question 5c.

5c. Provide relevant information below, include details if the score changed.

|      |

6. Offense Type: ask “Have you ever been adjudicated (found guilty of) for a sexual offense?”

|No |Score 0 |      | | |

|Yes |Score 4 |      | |Question 6: |

Does the juveniles’ response match collateral information? Yes, go to question 6b No, go to question 6a.

6a. Provide relevant information below, include details if the score changed.

|      |

6b. Sexual Aggression: ask” Have you ever been engaged in behavior that would be considered sexually aggressive?”

|No |Score 0 |      | | |

|Yes |Score 4 |      | |Question 6b: |

Does the juveniles’ response match collateral information? Yes, go to question 7 No, go to question 6c.

6c. Provide relevant information below, include details if the score changed.

|      |

7. Violent offense: ask “Have you ever been adjudicated (found guilty) for a violent offense? Refer to the Criteria Guide for determining violent offenses

|No |

8. Intellectual Impairment: From the file review is there any evidence that this youth has been previously reported to have an intellectual impairment (low IQ), learning disability or special education classes?

|No Evidence |Score 0 |      | | |

|Evidence |Score 2 |      | |Question 8: |

Lack of Fit Assessment

9. “Lack of fit” with juvenile facility culture: This item requires a judgment by the screener that this youth is unlikely to “fit in” within the mainstream juvenile culture. Place a check √ in the applicable box(s).

Place a check by features that apply to youth

| |Features of the youth’s physical appearance: | | |Features that might make youth standout such as: |

| |Small build | | |Having a lack of exposure to criminal lifestyle |

| |Looks younger than stated age | | |Being an ethnic minority not well represented (e.g. Vietnamese, Indian, |

| | | | |Middle Eastern) |

| |Impaired vision (wears glasses) | | |Membership in a gang that is likely to be a target of attack from others |

| |Pronounced disfigurement | | | |

| |Physical disability | | | |

| |Deaf | | | |

| |Appears frail, weak | | | |

Features of the youth presentation and behaviors such as:

| |Inappropriate verbal behavior (e.g. giggling, odd | | |Inappropriate behavior in school |

| |remarks) | | | |

| |Gender nonconformity | | |Speech impediment |

| |(e.g. cross-gender clothing, cross-gender | | | |

| |identity) | | | |

| |Hunched or fearful posture (e.g. very fearful, | | |Appears slow or “dull” |

| |very shy) | | | |

| |Observed acts of aggression | | |Behaviors that are likely to irritate and annoy other youth (e.g. |

| | | | |immature, silly) |

| |Inappropriate behavior with sibling(s) or other | | |Behaviors that appear related to mental illness (e.g. jittery, crying, |

| |residents | | |bizarre) |

Overall Risk Score – Transfer information from above here

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Approved

Disapproved |

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      | | | |

| | |Print Name | |Title | |Signature | |Date | |

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