ND CAWS

Sexual Assault Evidence Collection Protocol

Safety alert: Computer use can be monitored and is impossible to completely clear. If you are in danger, please use a safer computer, call your local hotline at 1-800-472-2911, and/or call the National Domestic Violence Hotline at
1-800-799-SAFE. If you are at a safer computer, click here to read more.

For a hard copy of the protocol please contact NDCAWS at 1-888-255-6240.

Child Sexual Abuse | Sexual Assault Laws | Statistics | ND Programs

LGBT Issues | Elder Abuse | Native American | Disabilities Issues

Sexual Assault Evidence Collection Protocol | State Plan

Return to Evidence Collection Protocol Index

STEP 1                          AUTHORIZATION FOR COLLECTION AND RELEASE
                                                               OF EVIDENCE AND INFORMATION

                                                    Victim’s Name:________________________
                                                    Date of Birth: _________________________
I,_____________________________________________ , freely consent to allow ______________________________M.D., his medical and nursing assistants and associates to conduct an examination to collect evidence concerning an alleged sexual assault. This procedure has been fully explained to me and I understand that this examination will include tests for the presence of sperm and venereal disease, as well as clinical observation for physical evidence of penetration of or injury to my person, or both, and the collection of other specimens and blood samples for laboratory analysis.

I fully understand the nature of the examination and the fact that medical information gathered by this means may be used as evidence.

I hereby authorize_____________________________to give law enforcement all
                                                      (Name of Hospital)
information you may have regarding my condition when under your observation or treatment on_______________________
                                 (Date of Examination)

This includes history, findings, x-rays, photographs and diagnosis, access to hospital records for examination, including photocopying such records.

__________________________ __________________________
(Dated) (Signature)

Relationship to victim if other than patient signing release:

Victim’s Parent

Guardian

Other (specify):_________________

List clothing or miscellaneous items to be released:_____________________
________________________________________________________________
________________________________________________________________

RECEIPT OF INFORMATION

I certify that I have received the following items (check those which apply):

One sealed evidence kit	X-rays or copies of x-rays	Photographs
Sealed clothing bag(s) (if more than one sealed clothing bag please note: __________________________________________________________
Other:______________________________________________

Signature of person receiving information and/or articles:________________________Date:_________ Time:___________

ID #/Shield #/Star #/Title: __________________Agency:_______________

Person receiving article(s) is representative of: ___________________________
Name of person releasing articles:_____________________________________
                                                                               (Printed Name)
                                                 _____________________________________
                                                                               (Signature)

White copy: Return to kit box. Pink copy: Retain for hospital records.

NDCAWS, 418 E Rosser Ste. 320, Bismarck, ND 58501
701-255-6240 888-255-6240 (toll free) 701-255-1904 (fax) [Email]

ND Services

ND Resource Directory

Rural Committee

Publicity Committee

Shelter Committee

Children & Youth Advocacy Committee

Batterer’s Treatment Forum

Sexual Assault Issues Prioritizing Committee

Native American Forum

Supervised Visitation Network