Proposed Revision to SSVIA

OMB No. 1121-0292: Approval Expires xx/xx/xxxx

SSV-IA

U.S. DEPARTMENT OF JUSTICE

FORM
(04-10-2024)

SURVEY OF SEXUAL VICTIMIZATION, 2023

BUREAU OF JUSTICE STATISTICS
and ACTING AS COLLECTION AGENT

U.S. DEPT. OF COMMERCE

Substantiated Incident Form (Adult)

U.S. CENSUS BUREAU

Incident Number ___ out of ___
1. Did the incident include repeated behaviors?
01

Yes

02

4. Did the incident take place in an area subject
to video monitoring? (Mark all that apply.)

No

01

If "Yes" ➔ a. On approximately, how many
different dates did it occur? . . .

02

➔ b. On what date did the most

If "No" ➔ a. On what date did the incident
occur?
Month
Day
Year

2. In what facility did the incident occur?
Name
State

3. Where did the incident occur? (Mark all that apply.)
01

In the victim’s cell or room (if the victim and perpetrator
share a cell or room, count as the victim’s cell)

02

In the perpetrator’s cell or room
In a dormitory or other multiple housing unit
In a common area (e.g., shower, dayroom, bathroom)
In a temporary holding cell or intake area within the
facility
In a program service area (e.g., commissary, kitchen,
storage, laundry, cafeteria, workshop, hallway)
In an instructional area (e.g., classroom, school, library,
conference room)

03
04
05
06
07
08

In a recreation area (e.g., yard, courtyard, gymnasium)

09
10

In a medical area (e.g., infirmary, health clinic)
In a staff area (e.g., office, break room, counselor’s office)

11

Offsite or while in transit

12

Other – Specify

13

Location unknown
Location not applicable (e.g., involved written, phone,
or virtual communication)

14

03

Unknown

5. What time did the incident occur?
(Mark all that apply.)
01
Morning (6 a.m. to 11:59 a.m.)
02
Afternoon (noon to 5:59 p.m.)
03
Evening (6 p.m. to 11:59 p.m.)
04
Overnight (midnight to 5:59 a.m.)
05
Time unknown

recent incident occur?
Month
Day
Year

City

Yes
No

6. Who reported the incident?
(Mark all that apply.)
01
Victim
02
Another inmate (non-victim)
03
Victim’s family, friend, or legal guardian
04
Correctional officer or front-line staff
05
Administrative staff
06
Medical, healthcare, or mental health staff
07
Instructor, teacher, or counselor
08
Other staff (e.g., kitchen worker, maintenance staff)
09
Chaplain or other religion official
10
Perpetrator
11
Perpetrator’s family, friend, or legal guardian
12
Grievance coordinator, grievance process, or ombuds
13
Attorney (victim’s or perpetrator’s)
14
Confidential informant, anonymous tip, hotline, or
through monitoring (e.g., camera, telephone, or mail)
15
Other – Specify

7. What was the type of sexual victimization incident?
(See definitions on page 9.)
01
Inmate-on-inmate sexual abuse
➞ Complete sections A and B
02
Inmate-on-inmate sexual harassment
➞ Complete sections A and B
03
Staff-on-inmate sexual abuse
➞ Complete sections A and C
04
Staff-on-inmate sexual harassment
➞ Complete sections A and C

Burden Statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB
control number. The burden of this collection is estimated to average 30 minutes per response, including reviewing instructions, searching
existing data sources, gathering necessary data, and completing and reviewing this form. Send comments regarding this burden estimate or
any aspect of this survey, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW,
Washington, DC 20531. Do not send your completed form to this address.

Section A – VICTIMS OF SEXUAL VICTIMIZATION
8. How many victims were involved in the
incident?
Number of victims . . . .
➔ If more than two victims were involved,
please complete this form online.
9. Victim #1: What was the victim’s sex assigned
at birth?
Sex is a multidimensional construct based on a cluster of
anatomical and physiological traits that include external
genitalia, secondary sex characteristics, gonads,
chromosomes, and hormones.
01
Male
02

Female

03

Intersex [A person whose sexual or reproductive
anatomy or chromosomal pattern does not seem
to fit typical definitions of male or female. Intersex
medical conditions are sometimes referred to as
differences in sex development.]

10. Victim #1: What was the victim’s gender
identity?
Gender identity is a person’s core internal understanding
or sense of who they are regardless of sex assigned at
birth.
01
Male
02
03
04

14. Victim #1: Was the victim identified as having
any of the following disabilities at the time
of the incident? (Mark all that apply.)
Disability is defined as (a) A physical or mental impairment
that substantially limits one or more of the major life
activities of [an] individual; (b) a record of such an
impairment; or (c) being regarded as having such an
impairment.
01

02

03

A serious and persistent mental illness (e.g., bipolar
disorder, major depression, obsessive compulsive
disorder, post-traumatic stress disorder, schizophrenia,
etc.)
A cognitive impairment or intellectual disability (e.g.,
ADHD, autism spectrum disorder, dementia, a learning
disability, etc.)
A physical impairment or disability (e.g., back or spinal
injury, blindness or low vision, deafness or hearing loss,
diabetes, epilepsy, heart disease, mobility impairments,
etc.)

15. Victim #1: Did the victim sustain any physical
injury during the incident?
01
Yes 02
No 03
Unknown
If "Yes" ➔ a. What injuries occurred?
(Mark all that apply.)

Female
Transgender [A person whose gender identity is
different from the person’s sex assigned at birth.]

01
02
03

Gender nonconforming [A person whose gender
identity does not conform to traditional societal
gender expectations.]

04
05
06

05
06

Other – Specify
Unknown

07
08
09
10

11. Victim #1: What was the victim’s age at the
time of the incident?
years

➔ b. Did the victim receive medical

treatment for these injuries?
Yes 02
No 03
Unknown

12. Victim #1: What was the victim’s race or
ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

01

16. Victim #1: After the incident was reported,
was the victim – (Mark all that apply.)
01
02
03
04
05
06
07

13. Victim #1: What was the victim’s citizenship?
01
02
03

Page 2

A U.S. citizen
Not a U.S. citizen
Of unknown citizenship status

Bruises, black eye, sprains, cuts,
scratches, swelling, welts
Bites
Burns
Chipped or knocked out teeth
Anal or vaginal tearing
Knocked unconscious
Broken bones
Knife or stab wounds
Internal injuries
Other – Specify

08
09

Provided with counseling or mental health treatment
Given a medical examination
Administered a sexual assault kit
Given post-exposure prophylaxis (PEP)
and/or emergency contraception
Tested for HIV/AIDS
Tested for other sexually transmitted infections
Offered but declined testing or treatment and/or
counseling
Already released/discharged
None of the above

FORM SSV-IA (04-10-2024)

Section A – VICTIMS OF SEXUAL VICTIMIZATION
17. Victim #1: After the incident was reported,
was the victim – (Mark all that apply.)

10

Separated from perpetrator
Confined to own cell or room
Placed in or returned to restrictive housing
Placed in a medical unit, ward, or hospital
Placed in camera room, under close surveillance,
or increased supervision
Transferred to another housing unit or dorm, or
given a single room or cell
Given a higher custody level or different unit within
the facility
Transferred to another facility
Issued disciplinary report or loss of privileges
Other – Specify

11

None of the above

01
02
03
04
05
06
07
08
09

➔ If there were no other victims, please skip

to Section B on pages 4-5 if the incident
involved an inmate perpetrator or Section C
on pages 6-7 if the incident involved a staff
perpetrator.

22. Victim #2: What was the victim’s citizenship?
01
02
03

23. Victim #2: Was the victim identified as having
any of the following disabilities at the time
of the incident? (Mark all that apply.)
01

02

03

Male

02

Female

03

01

Male

02

Female

03

Transgender

04

Gender nonconforming

02

Intersex

03
05

05

06
07

Other – Specify

08
09

06

10

Unknown

21. Victim #2: What was the victim’s race or
ethnicity? (Mark all that apply.)

05
06
07
08

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

Unknown

Bruises, black eye, sprains, cuts,
scratches, swelling, welts
Bites
Burns
Chipped or knocked out teeth
Anal or vaginal tearing
Knocked unconscious
Broken bones
Knife or stab wounds
Internal injuries
Other – Specify

treatment for these injuries?
Yes 02
No 03
Unknown

01

25. Victim #2: After the incident was reported,
was the victim – (Mark all that apply.)
01
02
03
04
05
06
07
08
09

FORM SSV-IA (04-10-2024)

03

➔ b. Did the victim receive medical

years

04

No

02

01

20. Victim #2: What was the victim’s age at the
time of the incident?

03

Yes

04

01

02

A physical impairment or disability (e.g., back or spinal
injury, blindness or low vision, deafness or hearing loss,
diabetes, epilepsy, heart disease, mobility impairments,
etc.)

If "Yes" ➔ a. What injuries occurred?
(Mark all that apply.)

19. Victim #2: What was the victim’s gender
identity?

01

A serious and persistent mental illness (e.g., bipolar
disorder, major depression, obsessive compulsive
disorder, post-traumatic stress disorder, schizophrenia,
etc.)
A cognitive impairment or intellectual disability (e.g.,
ADHD, autism spectrum disorder, dementia, a learning
disability, etc.)

24. Victim #2: Did the victim sustain any physical
injury during the incident?

18. Victim #2: What was the victim’s sex assigned
at birth?
01

A U.S. citizen
Not a U.S. citizen
Of unknown citizenship status

Provided with counseling or mental health treatment
Given a medical examination
Administered a sexual assault kit
Given post-exposure prophylaxis (PEP)
and/or emergency contraception
Tested for HIV/AIDS
Tested for other sexually transmitted infections
Offered but declined testing or treatment and/or
counseling
Already released/discharged
None of the above

Page 3

26. Victim #2: After the incident was reported,
was the victim – (Mark all that apply.)

10

Separated from perpetrator
Confined to own cell or room
Placed in or returned to restrictive housing
Placed in a medical unit, ward, or hospital
Placed in camera room, under close surveillance,
or increased supervision
Transferred to another housing unit or dorm, or
given a single room or cell
Given a higher custody level or different unit within
the facility
Transferred to another facility
Issued disciplinary report or loss of privileges
Other – Specify

11

None of the above

01
02
03
04
05
06
07
08
09

28. What types of pressure, coercion, or force
occurred as part of the incident?
(Mark all that apply.)
01
02
03
04
05
06
07

Persuasion or talked into sexual activity
Bribery or blackmail
Gave the victim drugs or alcohol
Offered protection from other inmates
Threats made (e.g., threatened harm to victim or
victim’s family, threatened with a weapon)
Unwanted touching, grabbing, or groping of the victim by
surprise or while the victim was asleep or incapacitated
Physically held victim down or restrained in some way,
including having other inmates restrain the victim

08

Physical harm or injury

09

Other – Specify

10

None of the above

29. How many inmate perpetrators were involved
in the incident?
Section B – INMATE PERPETRATORS OF
SEXUAL VICTIMIZATION
➔ If the perpetrator was a staff member, go to

Section C on pages 6-7.

27. What was the nature of the incident?
(Mark all that apply.)
01
02
03
04

05
06
07

Repeated verbal comments or gestures of a
derogatory or offensive sexual nature
Repeated and unwelcome sexual advances or
requests for sexual favors
Indecent exposure, masturbation, voyeurism, or
other actions of a derogatory sexual nature
Intentional and non-consensual or coerced touching
of the genitalia, anus, groin, breast, inner thigh,
or the buttocks
Nonconsensual sexual act that resulted from
pressure or coercion (without force)
Nonconsensual sexual act that resulted from
physical force (or the threat of force)
Other – Specify

Number of inmate perpetrators . . . .
➞ If more than two inmate perpetrators were
involved, please complete this form online.
30. Perpetrator #1: What was the inmate perpetrator’s
sex assigned at birth?
Sex is a multidimensional construct based on a cluster of
anatomical and physiological traits that include external
genitalia, secondary sex characteristics, gonads,
chromosomes, and hormones.
01
Male
02

Female

03

Intersex [A person whose sexual or reproductive
anatomy or chromosomal pattern does not seem
to fit typical definitions of male or female. Intersex
medical conditions are sometimes referred to as
differences in sex development.]

31. Perpetrator #1: What was the inmate perpetrator’s
gender identity?
Gender identity is a person’s core internal understanding
or sense of who they are regardless of sex assigned at
birth.
01

Male

02

Female
Transgender [A person whose gender identity is
different from the person’s sex assigned at birth.]

03
04

Gender nonconforming [A person whose gender
identity does not conform to traditional societal
gender expectations.]

05

Other – Specify
Unknown

06

Page 4

FORM SSV-IA (04-10-2024)

32. Perpetrator #1: What was the inmate
perpetrator’s age at the time of the incident?
years
33. Perpetrator #1: What was the inmate
perpetrator’s race or ethnicity?
(Mark all that apply.)
01
02
03
04
05
06
07
08

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

36. Perpetrator #2: What was the inmate
perpetrator’s gender identity?
(See definitions on page 9.)
01

Male

02

Female

03

Transgender

04

Gender nonconforming

14
15

Other – Specify

09
10
11
12
13

04
05
06
07
08

01
02
03
04
05
06
07

35. Perpetrator #2: What was the inmate
perpetrator’s sex assigned at birth?
01

Male

02

Female

FORM SSV-IA (04-10-2024)

03

Confined to own cell or room
Placed in or returned to restrictive housing
Placed in higher custody level, restricted unit or
program, within the same facility
Transferred to other unit/cell or separated from victim
Transferred to another facility
Sent to counseling or mental health treatment
Given medical treatment or testing
(e.g., post-exposure prophylaxis (PEP), HIV/AIDS)

14

Loss of "good/gain" time, increase in "bad" time or
delayed release
Given extra work
Loss of privileges, disciplinary report or conduct
violation, or other reprimand
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, given new sentence, or fined
Awaiting a legal outcome

15

Other – Specify

08

10

skip to Notes on page 8 (if applicable) or
submit form.

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

39. Perpetrator #2: After the incident, was the inmate
perpetrator – (Mark all that apply.)

09

➔ If there were no other perpetrators, please

Unknown

38. Perpetrator #2: What was the inmate
perpetrator’s race or ethnicity?
(Mark all that apply.)

03

Loss of "good/gain" time, increase in "bad" time or
delayed release
Given extra work
Loss of privileges, disciplinary report or conduct
violation, or other reprimand
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, given new sentence, or fined
Awaiting a legal outcome

06

years

01

08

Other – Specify

37. Perpetrator #2: What was the inmate
perpetrator’s age at the time of the incident?

02

34. Perpetrator #1: After the incident, was the
inmate perpetrator – (Mark all that apply.)
01
Confined to own cell or room
02
Placed in or returned to restrictive housing
Placed in higher custody level, restricted unit or
03
program, within the same facility
04
Transferred to other unit/cell or separated from victim
05
Transferred to another facility
06
Sent to counseling or mental health treatment
07
Given medical treatment or testing
(e.g., post-exposure prophylaxis (PEP), HIV/AIDS)

05

11
12
13

Intersex

Page 5

Section C – STAFF PERPETRATORS OF
SEXUAL VICTIMIZATION
➔ If the perpetrator was an inmate, go to

Section B on pages 4-5.

40. What was the nature of the incident?
(Mark all that apply.)
01
02
03

04
05
06
07
08
09

Repeated suggestive, derogatory, or obscene verbal
comments or gestures of a sexual nature
Wrote letters, showed pictures, talked on the phone, or
through video conferencing
Exhibited grooming or manipulative behaviors such
as providing gifts, special privileges, or favors to
inmates
Indecent exposure, invasion of privacy, or voyeurism
Any attempt, threat, or request related to abusive
sexual contact or sexual acts
Any touching or kissing for sexual gratification
Pressure or abuse of power resulting in a sexual act
Physical force resulting in a sexual act
Other – Specify

45. Staff #1: Was the staff perpetrator involved in
the incident –
01
02
03
04

46. Staff #1: What was the primary position
description of the staff perpetrator involved in
the incident?
01
02

03

04
05

09
10

Other staff – Specify

07

Number of staff . . . .

Correctional officer, supervisory or security staff, or
direct care staff
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
Medical or healthcare staff, including counselors,
doctors, dentists, psychologists, psychiatrists, social
workers, nurses, and medical assistants
Education staff, including instructors, teachers,
librarians, and education assistants
Member of the clergy or chaplaincy
Administrator, including wardens, superintendents,
assistants and others in administrative positions
Clerical staff including secretaries, clerks,
receptionists, and other administrative support
Other program staff
Volunteers or interns

06

41. How many staff perpetrators were involved in
the incident?

Full or part-time paid employee
Contract employee or vendor
Volunteer or intern
Other – Specify

08

➞ If more than two staff were involved, report
please complete this form online.
42. Staff #1: What was the staff perpetrator’s
gender?
01

Male

02

Female

43. Staff #1: What was the staff perpetrator’s age
at the time of the incident?
years
44. Staff #1: What was the staff perpetrator’s race
or ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

47. Staff #1: At the time of the incident, how long
had the staff perpetrator worked at the
facility?
01
Less than 6 months
02
6 months to 1 year
03
1 to 5 years
04
6 to 10 years
05
11 or more years
48. Staff #1: After the incident, was the staff
perpetrator – (Mark all that apply.)

12

Sent to training or counseling
Reprimanded or disciplined
Transferred to another facility or unit
Demoted, diminished responsibilities, suspended
temporarily, or placed on administrative leave
Discharged, terminated, or contract not renewed
Staff resigned (prior to completion of investigation)
Staff resigned (after investigation was completed)
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, sentenced, or fined
Awaiting a legal outcome
Other – Specify

13

No action taken

01
02
03
04
05
06
07
08
09
10
11

Page 6

FORM SSV-IA (04-10-2024)

➞ If there were no other staff perpetrators
involved, please skip to Notes on page 8
(if applicable) or submit form.
49. Staff #2: What was the staff perpetrator’s
gender?
01

Male

02

Female

50. Staff #2: What was the staff perpetrator’s age
at the time of the incident?
years
51. Staff #2: What was the staff perpetrator’s race
or ethnicity? (Mark all that apply.)
01
02
03
04
05
06
07
08

White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Other racial category in your information system –
Specify

52. Staff #2: Was the staff perpetrator involved in
the incident –
01
02
03
04

Full or part-time paid employee
Contract employee or vendor
Volunteer or intern
Other – Specify

53. Staff #2: What was the primary position
description of the staff perpetrator involved in
the incident?
01
Correctional officer, supervisory or security staff, or
direct care staff
02
Maintenance and other facility support staff,
including groundskeepers, janitors, cooks, and
drivers
03
Medical or healthcare staff, including counselors,
doctors, dentists, psychologists, psychiatrists, social
workers, nurses, and medical assistants
Education staff, including instructors, teachers,
04
librarians, and education assistants
05
Member of the clergy or chaplaincy
06
Administrator, including wardens, superintendents,
assistants and others in administrative positions
07
Clerical staff including secretaries, clerks,
receptionists, and other administrative support
08
Other program staff
09
Volunteers or interns
10
Other staff – Specify

54. Staff #2: At the time of the incident, how long
had the staff perpetrator worked at the
facility?
01
Less than 6 months
02
6 months to 1 year
03
1 to 5 years
04
6 to 10 years
05
11 or more years
55. Staff #2: After the incident, was the staff
perpetrator – (Mark all that apply.)

12

Sent to training or counseling
Reprimanded or disciplined
Transferred to another facility or unit
Demoted, diminished responsibilities, or
suspended temporarily, or placed on administrative
leave
Discharged, terminated, or contract not renewed
Staff resigned (prior to completion of investigation)
Staff resigned (after investigation was completed)
Arrested or referred to law enforcement agency
Referred for prosecution or indicted
Convicted, plead guilty, sentenced, or fined
Awaiting a legal outcome
Other – Specify

13

No action taken

01
02
03
04

05
06
07
08
09
10
11

FORM SSV-IA (04-10-2024)

Page 7

NOTES

Page 8

FORM SSV-IA (04-10-2024)

DEFINITIONS
Sexual victimization
Inmate-on-inmate sexual abuse: Sexual abuse of an inmate, detainee, or resident by another inmate, detainee, or resident
includes any of the following acts, if the victim does not consent, is coerced into such act by overt or implied threats of violence, or
is unable to consent or refuse:
1) Contact between the penis and the vulva or the penis and the anus, including penetration, however slight;
2) Contact between the mouth and the penis, vulva, or anus;
3) Penetration of the anal or genital opening of another person, however slight, by a hand, finger, object, or other instrument; and
4) Any other intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or the
buttocks of another person, excluding contact incidental to a physical altercation.
Inmate-on-inmate sexual harassment: Repeated and unwelcome sexual advances, requests for sexual favors, or verbal
comments, gestures, or actions of a derogatory or offensive sexual nature by one inmate, detainee, or resident directed toward
another.
Staff-on-inmate sexual abuse: Sexual abuse of an inmate, detainee, or resident by a staff member, contractor, or volunteer
includes any of the following acts, with or without consent of the inmate, detainee, or resident:
1) Contact between the penis and the vulva or the penis and the anus, including penetration, however slight;
2) Contact between the mouth and the penis, vulva, or anus;
3) Contact between the mouth and any body part where the staff member, contractor, or volunteer has the intent to abuse, arouse, or
gratify sexual desire;
4) Penetration of the anal or genital opening, however slight, by a hand, finger, object, or other instrument, that is unrelated to official
duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or gratify sexual desire;
5) Any other intentional contact, either directly or through the clothing, of or with the genitalia, anus, groin, breast, inner thigh, or the
buttocks, that is unrelated to official duties or where the staff member, contractor, or volunteer has the intent to abuse, arouse, or
gratify sexual desire;
6) Any attempt, threat, or request by a staff member, contractor, or volunteer to engage in the activities described in paragraphs
(1) - (5) of this section;
7) Any display by a staff member, contractor, or volunteer of his or her uncovered genitalia, buttocks, or breast in the presence of an
inmate, detainee, or resident, and
8) Voyeurism by a staff member, contractor, or volunteer.
Staff-on-inmate sexual harassment: Repeated verbal comments or gestures of a sexual nature to an inmate, detainee, or
resident by a staff member, contractor, or volunteer, including demeaning references to gender, sexually suggestive or derogatory
comments about body or clothing, or obscene language or gestures.
Sex and gender identity
Sex: A multidimensional construct based on a cluster of anatomical and physiological traits that include external genitalia,
secondary sex characteristics, gonads, chromosomes, and hormones.
Gender identity: A person’s core internal understanding or sense of who they are regardless of sex assigned at birth.
Intersex: A person whose sexual or reproductive anatomy or chromosomal pattern does not seem to fit typical definitions of
male or female. Intersex medical conditions are sometimes referred to as differences in sex development (DSD).
Gender nonconforming: A person whose appearance or manner does not conform to traditional societal gender expectations.
Transgender: A person whose gender identity is different from the person’s sex assigned at birth.
Disability
Disability: A (1) physical or mental impairment that substantially limits one or more of the major life activities of [an] individual;
(2) a record of such an impairment; or (3) being regarded as having such an impairment.

FORM SSV-IA (04-10-2024)

Page 9