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2. Name(s) of Inmate (Victim)*
3. Inmate(s) (Victim) PID
5. Name(s) of Alleged Perpetrator(s)
6. Name(s) of Witnesses
8. Date & Time of Incident
   Date & Time of Incident

   Date & Time of Incident
9. Did the incident occur inside the Jail?

   1. Yes
   2. No
11. Location of Where the Incident Occurred
13. Any Additional Relevant Information
15. Your Name & Contact Information (Optional)
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17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit

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