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.
(Please print, type or use a
patient information stamp)
Victim
Name: _______________________
Hospital Name: ______________________
Date of Examination: _________________
Examining Physician: ________________
Hospital Telephone No:________________
(Patient Stamp)
A number of specimens were
collected from you to provide evidence in court should
your attacker be caught and you decide to prosecute.
Additional tests were conducted as follows:
1. A blood
test for syphilis
Yes
No
2. Smear
and culture for:
Gonorrhea
Yes
No
Chlamydia
Yes
No
3.
Pregnancy test to determine
pre-existing pregnancy only
Yes
No
You
were given an antibiotic to prevent gonorrhea. However,
you must return 4 – 6 weeks* following this treatment for
another test to be sure that you do not have syphilis. You
need to return for this test and possible treatment the
week of:___________________________
Name of Medication: ___________________
Dosage:___________________
You
were not given treatment to prevent gonorrhea or any other
venereal disease because:
________________________________________________________________
If you wish counseling,
referrals and/or follow-up testing and treatment for
venereal disease from an agency other than this hospital,
call one of the agencies listed below for assistance:
________________________________________________________________
________________________________________________________________
________________________________________________________________
An
appointment was made for you at this hospital for
follow-up medical
treatment on _______________
(Date)
No
appointment was made for follow-up treatment.
An
appointment was made for you at this hospital for
follow-up counseling on
_________________
(Date)
I
have received this Victim Information Form
__________________________
(Victim/Parent/Guardian Signature)
I
do not wish to receive this
Form___________________________________
(Victim/Parent/Guardian Signature)
*Physicians see STD Guideline
White copy: Give to victim or parent/guardian
Pink copy: Retain for hospital records
