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 AND/OR CALL THE NATIONAL DOMESTIC VIOLENCE HOTLINE. IF YOU ARE AT A SAFER COMPUTER, CLICK HERE TO READ MORE. THERE IS ALWAYS A COMPUTER TRAIL, BUT YOU CAN LEAVE THIS SITE QUICKLY IF YOU CLICK ESCAPE.
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.
STEP 2
SEXUAL ASSAULT REPORT FORM FOR FORENSIC LABORATORY
Name of
Victim:_____________________ Age:_____ Sex:______
Race:________
Date of Collection: ___________________Time of
Collection:_________ (AM/PM)
Date of Assault: __________Time of Assault:_________ Sex
of Assailant(s):____
Assailant(s) (if
known):________________________________________________
Race of Assailant(s) (if known): _________________Number
of Assailants: _____
Assailant(s) relationship to victim:
Stranger
Acquaintance
Relative
(specify):_________________
Prior to evidence
collection, victim has:
Douched
Bathed
Urinated
Defecated
Had
Food or Drink
Brushed
Teeth/Used Mouthwash
Changed
Clothes
Vomited
None
of the Above
At time of assault, was:
Contraceptive foam or spermacide present?
Yes
No
Don’t
Know
Lubricant used by assailant?
Yes
No
Don’t
Know
Condom used by assailant?
Yes
No
Don’t
Know
Tampon present?
Yes
No
Don’t
Know
Victim menstruating?
Yes
No
Don’t
Know
At time of exam, was
tampon present?
Yes
No
Menstruation at time of exam?
Yes
No
Was victim bleeding from any wounds inflicted by
assailant?
Yes
No
Any consensual coitus in the previous 72 hours?
Yes
No
If yes, Date: _______________and Time:_______________
If yes, was condom used?
Yes
No
COMMUNICABLE DISEASES OF RISK TO LAB PERSONNEL: (e.g.,
Hepatitis, TB, Herpes, HTLV/III, etc.) and/or presence
of parasites (e.g., head lice, crab lice, body lice,
mites,
etc.):________________________________________________
___________________________________________________________________
PHYSICAL EXAMINATION: (Include pertinent medical
details of trauma, secretions on body and clothing,
Wood’s Lamp/black light examination, if
available):___________________________________________________________
___________________________________________________________________
HISTORY: (Pertinent details of assault: e.g., oral,
anal, vaginal penetration; penetration manually or
with other foreign object; oral contact by victim;
ejaculation, if known by
victim.)_________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
White copy: Return to kit box
Pink copy: Retain for hospital records
