Sample Form For Consent/Refusal and Evidentiary Log

*Adapted from a form developed by St. Lukes-Roosevelt Hospital Center

Date:_______________ Time of Exam:_______________AM/PM

Patient Name:_________________________________________ Contact No.:__________________________

SAFE * 1)_______________________________________ Contact No.:__________________________

Examiner(s)
2)_______________________________________ Contact No.:__________________________

Provider: ______________________________ Dept.:__________ Contact No.:__________________________

(If not a SAFE* Examiner)
*Sexual Assault Forensic Examiner
Patient Consent/Refusal
I understand that if I consent, an examination for evidence of sexual assault and collection of possible evidence
will be conducted. I understand that I may refuse to consent, or I may withdraw consent at any time for any
portion of the examination. I understand that the collection of evidence may include photographing injuries, which
may include injuries to the genital area. I understand that if I consent, such evidence will be released to the police
at this time. If I do not consent to release of evidence at this time, such evidence will be preserved at the Hospital
for not less than 30 days.

I consent to:
Physical Examination: _____Yes _____No
Photographing of Injuries: _____Yes _____No
Collection of Evidence: _____Yes _____No
Release of Evidence to Police: _____Yes _____No
Verbal Communications by
Hospital Personnel with
Prosecutorial Agency: _____Yes _____No

Signature of Patient______________________________________________________Date________________

Signature of Witness_____________________________________________________Date________________

Print Name of Witness____________________________________________________

LOG OF ITEMS TAKEN FROM PATIENT FOR EVIDENCE

1) 4)

2) 5)

3) 6)

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 COMPREHENSIVE SEXUAL ASSAULT ASSESSMENT FORM
PLEASE PRINT CLEARLY
1. INITIAL ASSESSMENT

Date of Birth: _________________ _______Male ________Female

__African Descent __Asian/Pacific Islander __Caucasian __Hispanic Other_________

Physical Disability: ___Yes __No If Yes describe___________________________________

Primary Language if not English ________________________________ Was interpreter used ____________

2. PERTINENT PAST MEDICAL HISTORY

______________________________________________________________________________________________________________

LMP: _______________ Allergies_______________________________________________________

Medications:__________________________________________________________________________________

Last Tetanus Immunization:___________________ Hepatitis B Immunization Yes No If yes date__________

3. SEXUAL ASSAULT HISTORY

Date of Sexual Assault:__________________ Time of Sexual Assault:_________________________AM/PM

Time Elapsed between Assault and Exam: __________days ___________hours

Location of Sexual Assault (include exact address if known):_____________________________________________________________

_____________________________________________________________________________________________________________

Type of Violations Perpetrated against Survivor during Sexual Assault:

Vaginal Contact Yes No Unsure Oral Contact (offender to survivor) Yes No Unsure
Anal Contact Yes No Unsure Oral Contact (survivor to offender) Yes No Unsure
Condom Used Yes No Unsure
Use of Foreign Object Yes No Unsure If Yes describe____________________________________________
Foam/Jelly/Lubricant Yes No Unsure If Yes describe____________________________________________
Use of Weapon Yes No Unsure If Yes describe____________________________________________
Other:______________________________________________________________________________________________________

Brief Narrative of Assault (optional)______________________________________________________________________________

___________________________________________________________________________________________________________
Actions Before or After Assault

Has the survivor had consensual sex within the last 96 hours? Yes No Unsure If Yes when:__________________
After the sexual assault, has the survivor:
Urinated? Yes No Bathed/showered? Yes No Changed underwear? Yes No

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 COMPREHENSIVE SEXUAL ASSAULT ASSESSMENT FORM
PLEASE PRINT CLEARLY
4. PHYSICAL EXAMINATION General Appearance

General Medical Examination (use Traumagram on pages 6,7,8 as appropriate)

Colposcopic Examination to be completed prior to pelvic exam and forensic evidence collection
(use Traumagram on pages 6,7,8 as appropriate)

Female
Labia majora____________________________________ Vagina_______________________________________

Labia minora____________________________________ Hymen_______________________________________

Clitoris_________________________________________ Cervix________________________________________

Posterior fourchette_______________________________ Perineum______________________________________

Fossa navicularis__________________________________ Anus__________________________________________

Periurethral______________________________________ Rectum________________________________________

Vestibule________________________________________ Other__________________________________________

Male
Penis____________________________________________ Rectum_________________________________________

Perineum_________________________________________ Scrotum_________________________________________

Anus_____________________________________________ Other____________________________________________

Pelvic/Genital Examination
Female
Labia majora____________________________________ Vagina_______________________________________

Labia minora____________________________________ Hymen_______________________________________

Clitoris_________________________________________ Cervix________________________________________

Posterior fourchette_______________________________ Perineum______________________________________

Fossa navicularis__________________________________ Anus__________________________________________

Periurethral______________________________________ Rectum________________________________________

Vestibule________________________________________ Other__________________________________________

Male
Penis____________________________________________ Rectum_________________________________________

Perineum_________________________________________ Scrotum_________________________________________

Anus_____________________________________________ Other____________________________________________

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 COMPREHENSIVE SEXUAL ASSAULT ASSESSMENT FORM
PLEASE PRINT CLEARLY

5. EXAMINATION TECHNIQUES

Direct Visualization Yes No Evidence Kit Collected Yes No

If Yes
Bimanual Exam Yes No Photos Taken Yes No How many?___________

Speculum Exam Yes No Area(s) of Body Photographed:________________________________

Colposcopic Exam Yes No _________________________________________________________

Toluidene Blue Yes No _________________________________________________________

Woods Lamp Yes No _________________________________________________________

Anoscope Yes No _________________________________________________________

6. DIAGNOSTIC TESTS

Pregnancy Test Yes No Chlamydia Yes No

Gonorrhea: Cervical Yes No VDRL Yes No

Urethral Yes No Hepatitis B Serologies Yes No

Rectal Yes No Specimens (urine and/or blood

for diagnosis of drug-facilitated
Pharyngeal Yes No sexual assault) Yes No

7. STD PROPHYLAXIS
Gonorrhea Yes No Chlamydia Yes No Trichomonas/BV Yes No Hepatitis B Yes No

8. HIV POST-EXPOSURE PROPHYLAXIS 9. POST-COITAL CONTRACEPTION

Referral Sheet Completed (see next page) Yes No Yes No

10. REFERRALS GIVEN

Rape Crisis or Crime Victims Treatment Center ___ Gyn Clinic___ Patients Primary Care MD___

11. CHAIN OF CUSTODY

Name of Person Receiving
Evidence________________________________________________________________________________

ID#/Shield#________________________________
Agency_____________________________________________________

ADDITIONAL NOTES OR COMMENTS

PROVIDER SIGNATURE

_____________________________________________________________________

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 SAMPLE SEXUAL ASSAULT PATIENT HIV PEP: REFERRAL SHEET
PLEASE PRINT
CLEARLY

Patient Name: ____________________________________________________

Patient MR#: ______________________________ Age of Patient: _________

Date of Assault: ________________ Time of Assault: _____________

Date of Emergency Department Visit: _________________________

Date of Patient's Follow-up Appointment: ______________________

Time 1st Dose of PEP Given: _______ Date (if different from ED Visit): _______

PEP Medications Given: ____________________________________________

Labs Sent: CBC Yes No Chem 18 (Admission Panel) Yes No

Hepatitis B serology Yes No
Hepatitis C serology Yes No
Urine pregnancy test result: Positive Negative

Patient Rx'ed for GC, Chlamydia and Syphilis: Yes No Hep B Vaccine: Yes No

Emergency Contraception Provided: Yes No

Check here if patient requests HIV testing only (without HIV PEP):

Provider Name: ____________________________ MD PA NP RN

(Please print)

NOTE: Arrange for timely referral to clinic or provider for HIV PEP management.

Referral made to: __________________________________________________

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Male Traumagram

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Female Traumagram

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