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
| |
| |
Approved
Disapproved |
| |
| | | |
| | |Print Name | |Title | |Signature | |Date | |
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