United States Government Accountability Office Report to Congressional Requesters March 2016 SEXUAL ASSAULT Information on Training, Funding, and the Availability of Forensic Examiners GAO-16-334 March 2016 SEXUAL ASSAULT Information on Training, Funding, and the Availability of Forensic Examiners Highlights of GAO-16-334, a report to congressional requesters Why GAO Did This Study What GAO Found In 2013, about 285,000 individuals age 12 or older were reported victims of sexual assault, according to the Bureau of Justice Statistics. Studies have shown that exams performed by sexual assault forensic examiners— medical providers trained in collecting and preserving forensic evidence— may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates. Yet, concerns have been raised about the availability of examiners. The Violence Against Women Reauthorization Act of 2013 authorized funding for DOJ grant programs that can be used by states and other eligible entities, such as nonprofit organizations, to train and fund examiners. Federal funding from three key Department of Justice (DOJ) grant programs can be used to train or fund sexual assault forensic examiners and for a range of other activities related to sexual assault, domestic violence, dating violence, and stalking. In 2013, at least one grantee in 49 states used such funds to provide training to examiners and at least one grantee in 26 states funded examiner positions. In 49 states, approximately 227 grantees or subgrantees—referred to collectively as grantees—reported providing training for over 6,000 examiners in 2013. The type of training examiners received ranged from comprehensive examiner training to training on specific topics, such as courtroom testimony. The extent of examiner training efforts supported with funds from the three DOJ grant programs varied by state. For example, in about half of the states, fewer than 100 examiners received training. In addition, in the states where at least one grantee funded examiner staff positions in 2013, grantees funded less than one position, on average. Approximately 75 grantees in 26 states funded roughly 50 full-time equivalent examiner positions in 2013. GAO was asked to review the availability of examiners nationwide. In this report, GAO describes (1) the prevalence and use of federal grants to train or fund sexual assault forensic examiners, (2) what is known about the availability of such examiners nationwide and in selected states, and (3) the challenges selected states face in maintaining a supply of examiners. GAO analyzed 2013 DOJ data on grantees’ use of funding to train or fund examiners—the most recent full year of data available—and reviewed literature, relevant laws and DOJ documentation. GAO also interviewed grantees in six states selected based on several factors including population and geographic location, as well as DOJ officials, Department of Health and Human Services officials, and experts, such as health care association officials. View GAO-16-334. For more information, contact Katherine M. Iritani at (202) 512-7114 or iritanik@gao.gov. On the basis of literature GAO reviewed as well as interviews with experts and state officials, data on the number of examiners nationwide and in selected states are limited or unavailable. However, officials in all six selected states told GAO that the number of examiners available in their state did not meet the need for exams, especially in rural areas. For example, officials in Wisconsin explained that nearly half of all counties in the state do not have any examiners available. In health care facilities where examiners are available, they are typically available in hospitals on an on-call basis, though the number available varies by facility and may not provide enough capacity to offer examiner coverage 24 hours, 7 days a week. There are multiple challenges to maintaining a supply of examiners, according to interviews with officials in six selected states. These include: • • • Limited availability of training. Officials in five of six selected states reported that the availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of trained examiners. Weak stakeholder support for examiners. Officials in five of six selected states reported that obtaining support from stakeholders, such as hospitals, was a challenge. For example, hospitals may be reluctant to cover the costs of training examiners or paying for examiners to be on-call. Low examiner retention rates. The above-mentioned and other challenges, including the emotional and physical demands on examiners, contribute to low examiner retention rates. Officials in one state estimated that while the state trained 540 examiners over a two-year period, only 42 of those examiners were still practicing in the state at the end of those 2 years. Officials described strategies that can help address these challenges, such as implementing web-based training courses, clinical practice labs, mentorship programs, and multidisciplinary teams that respond to cases of sexual assault. DOJ provided technical comments on a draft of this report, which GAO incorporated as appropriate. United States Government Accountability Office Contents Letter 1 Background Most States Had at Least One Grantee That Used Federal Grant Funds to Train or Fund Examiners Nationwide Data on the Availability of Sexual Assault Forensic Examiners Are Limited; Officials in Selected States Reported a Need for Additional Examiners Selected States Faced Challenges Training Examiners, Maintaining Stakeholder Support, and Retaining Examiners Agency Comments Appendix I Appendix II 5 14 21 26 31 State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training 33 GAO Contact and Staff Acknowledgements 39 Tables Table 1: Total Amount of Grant Awards from Three Department of Justice Grant Programs That May Be Used to Train or Fund Sexual Assault Forensic Examiners, Fiscal Year 2015 Table 2: Number of Sexual Assault Forensic Examiners Who Received Training Provided by Grantees, 2013 Table 3: Number of Full-time Equivalent (FTE) Sexual Assault Forensic Examiner Positions Funded by Grantees, 2013 Table 4: Estimated Number of Practicing Sexual Assault Forensic Examiners and Examiner Programs in Selected States, As of January 2016 Table 5: Total Number of Services-Training-Officers-Prosecutors (STOP) Violence Against Women Formula Grant Program Grantees that Provided Training for Sexual Assault Forensic Examiners, and Total Number of Examiners Who Received Training by State, 2013 Table 6: Total Number of Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest) Grantees that Provided Training for Sexual Assault Page i 12 15 20 22 33 GAO-16-334 Sexual Assault Exam Readiness Forensic Examiners, and Total Number of Examiners Who Received Training by State, 2013 and 2014 Table 7: Total Number of Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural) Grantees that Provided Training for Sexual Assault Forensic Examiners, and Total Number of Examiners Who Received Training by State, 2013 and 2014 35 37 Figure Figure 1: Number of Sexual Assault Forensic Examiners Who Received Training Provided by Federal Grantees in 2013, by State 17 Abbreviations ACEP American College of Emergency Physicians DOJ Department of Justice FTE full-time equivalent HHS Department of Health and Human Services IAFN International Association of Forensic Nurses OVW Office on Violence Against Women NSVRC National Sexual Violence Resource Center SANE Sexual Assault Nurse Examiner STOP Services-Training-Officers-Prosecutors (STOP) Violence Against Women Formula Grant Program VAWA Violence Against Women Act This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-16-334 Sexual Assault Exam Readiness Letter 441 G St. N.W. Washington, DC 20548 March 18, 2016 The Honorable Patty Murray Ranking Member Committee on Health, Education, Labor and Pensions United States Senate The Honorable Sheldon Whitehouse Ranking Member Subcommittee on Crime and Terrorism Committee on the Judiciary United States Senate The Honorable Kelly Ayotte United States Senate The Honorable Al Franken United States Senate An estimated 284,350 individuals age 12 or older were victims of rape or other sexual assault in 2014, according to the most recently available data from the Bureau of Justice Statistics. 1 When victims of sexual assault receive a medical forensic examination, the exam may be provided by either a trained sexual assault forensic examiner—that is, a medical provider who has received specialized training in properly collecting and preserving forensic evidence—or a medical provider who has not received such specialized training. Studies have shown that exams performed by trained sexual assault forensic examiners may result in shortened exam time, better quality health care delivered to victims, higher quality forensic evidence collection, as well as better collaboration 1 Data presented are from the Bureau of Justice Statistics’ 2014 National Crime Victimization Survey. See J. L. Truman and L. Langton, Criminal Victimization, 2014, NCJ 248973 (Washington, D.C.: Department of Justice, Sept. 29, 2015). Page 1 GAO-16-334 Sexual Assault Exam Readiness with the legal system and higher prosecution rates. 2 However, concerns have been raised about the availability of examiners to meet victims’ needs for exams. The Violence Against Women Act (VAWA), most recently reauthorized in 2013, authorized funding for federal grant programs administered by the Department of Justice (DOJ) that can be used by states and other eligible entities to, among other things, train sexual assault forensic examiners or fund examiner positions. 3 You asked us to review sexual assault victims’ access to health care facilities with medical providers trained in conducting sexual assault forensic examinations. This report describes: 1. the prevalence and use of federal grants to train and fund sexual assault forensic examiners; 2. what is known about the availability of sexual assault forensic examiners nationally and in selected states; and 3. the challenges selected states face in maintaining a supply of sexual assault forensic examiners. To describe the prevalence and use of federal grants to train or fund sexual assault forensic examiners, we asked officials at DOJ and the Department of Health and Human Services (HHS) to identify and describe federal grant programs from which funds are available for these 2 See, for example, R. Campbell, D. Patterson, and L. R. Lichty, “The Effectiveness of Sexual Assault Nurse Examiner (SANE) Programs: A Review of Psychological, Medical, Legal, and Community Outcomes,” Trauma, Violence, & Abuse vol. 6, no. 4 (2005); M. C. Howell et al., Compendium of Sexual Assault Research (Santa Monica, C.A.: The RAND Corporation, 2009); and R. Campbell et al., “The Impact of Sexual Assault Nurse Examiner (SANE) Program Services on Law Enforcement Investigational Practices: A Mediational Analysis,” Criminal Justice and Behavior vol. 39, no. 2 (2012). 3 In this report, the term “VAWA” refers to the Violence Against Women Act of 1994 as well as the laws reauthorizing it. See Violence Against Women Act of 1994, Pub. L. No. 103322, tit. IV, 108 Stat. 1796, 1902-55 (1994); Violence Against Women Act of 2000, Pub. L. No. 106-386, div. B, 114 Stat. 1464, 1491-1539 (2000); Violence Against Women and Department of Justice Reauthorization Act of 2005, Pub. L. No. 109-162, 119 Stat. 2960 (2006); Violence Against Women Reauthorization Act of 2013, Pub. L. No. 113-4, 124 Stat. 54 (2013). Page 2 GAO-16-334 Sexual Assault Exam Readiness purposes. Officials identified three key federal grant programs. 4 We reviewed relevant laws as well as DOJ guidance and reports related to the three grant programs and to sexual assault forensic exams and examiners. We also analyzed data submitted to DOJ by grantees of these three programs. Specifically, we analyzed data on the number of grantees that used funds to provide training for or fund examiner positions as well as the number of examiners who received training or examiner positions funded in 2013 and, where available, 2014. 5 To assess the reliability of the data, we reviewed documentation and interviewed DOJ officials about how the data were collected and verified, and we checked the data for obvious errors. We found the data to be sufficiently reliable for our purposes of describing the prevalence and use of federal grants to train or fund examiners. We also reviewed grantees’ open-ended responses to questions on grantee progress reporting forms about the status of achieving their grant goals and objectives, reported effectiveness of and other information about their training activities, and grantee perceptions about the most significant areas of remaining need with regard to training or funding examiners. We restricted our review of open-ended responses to those that mentioned terms related to sexual assault forensic 4 The three grant programs are: (1) Services-Training-Officers-Prosecutors Violence Against Women Formula Grant Program (STOP Grant Program); (2) Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest Grant Program); and (3) Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural Grant Program). Unless otherwise noted, we limited our analysis to the 50 states and the District of Columbia. We excluded tribal communities, the Indian Health Service, and the military health system from our analysis given recent GAO reports that examined the ability of Indian Health Service and tribally operated facilities, and military health system facilities to collect and preserve medical forensic evidence involving cases of sexual assault. See GAO, Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence GAO-12-29 (Washington, D.C.: October 2011); and GAO, Military Personnel: DOD Has Taken Steps to Meet the Health Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims GAO-13-182 (Washington, D.C.: January 2013). 5 We analyzed 2013 DOJ data for all three grant programs as well as data from January through June 2014 for Arrest and Rural grantees; STOP grantee data for 2014 were not yet available as of June 2015. We excluded from our analysis grantees that identified themselves as a tribal coalition, tribal government, or tribal sexual assault and/or domestic violence program. Although DOJ collects data on the estimated percentage of funding that grantees used to address broad categories of victimization, including sexual assault, DOJ officials told us the data are not collected in a manner in which it could be used to determine the dollar amount of funding that went towards providing training for examiners or funding examiner positions. Page 3 GAO-16-334 Sexual Assault Exam Readiness examiners. We interviewed experts, such as officials from the International Association of Forensic Nurses (IAFN), about the availability of federal grant funding to train or fund examiners. And, to further examine how grantees used funds to train or fund examiners, such as the type of training provided or examiner positions funded, we interviewed a selection of grantees in six selected states. To select the six states (Colorado, Florida, Massachusetts, Nebraska, Oregon, and Wisconsin), we considered the number of grantees in each state that received funding from any of the three grant programs; whether states had unique policies or programs in place regarding the training of examiners; and state population size and geographic location. We sought to achieve variation in these characteristics when selecting the six states. In the six selected states, we interviewed a total of nine grantees that received federal funds in fiscal year 2014. 6 Information from these interviews cannot be used to generalize beyond the six selected states. To examine what is known about the availability of sexual assault forensic examiners nationwide and in the six selected states, we conducted a literature review to identify studies that measured the availability of sexual assault forensic examiners. Two analysts independently reviewed all studies identified through a structured literature search for relevance. 7 We determined that a study was directly related to this objective if it measured the extent to which examiners were available in health care facilities at a national, state, or local level. Through these searches, we identified a total of 214 studies, of which 8 were determined relevant to this objective. During interviews with experts, grantees, and state sexual assault coalition officials in the six selected states, we asked about requirements and guidance concerning the training or availability of examiners; data on the availability of examiners or examiner programs; the extent to which examiner availability meets the need for exams; and 6 Within each state, we interviewed officials from the state agency that received STOP grant funding, referred to as the state STOP administrator. We also interviewed Arrest and Rural grantees that were awarded funds in fiscal year 2014 and told us that they used grant funds to train or fund sexual assault forensic examiners. We interviewed a total of six STOP grantees, two Arrest grantees, and one Rural grantee. 7 We performed a structured search of 21 reference databases, including MEDLINE®, CINHAL®, and ProQuest, for studies published on this topic between January 1, 2000, and June 1, 2015. To supplement this search, we also searched two websites—the National Online Resource Center on Violence Against Women and the National Sexual Violence Resource Center (NSVRC)—that serve as repositories of information about sexual assault. Page 4 GAO-16-334 Sexual Assault Exam Readiness examiner staffing characteristics in facilities where they are located. 8 Last, we reviewed information from three health care associations on their policies and guidance concerning the training of medical providers to perform exams and research they conducted on the availability of examiners. To examine the challenges selected states face in maintaining a supply of trained sexual assault forensic examiners, during our interviews with grantees and coalition officials in the six selected states we asked about challenges they experienced in training or retaining examiners and strategies that could be used to overcome these challenges. We also reviewed studies identified through our literature search that examined challenges to training and retaining examiners and strategies that can be used to address these challenges. Two analysts independently reviewed all studies identified for relevance. We determined that a study was directly related to this objective if it mentioned any challenges to training or maintaining examiners or examiner programs. From the 214 studies we identified through our literature search, we determined 16 to be relevant for this objective. We conducted this performance audit from April 2015 to March 2016 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background Sexual Assault Forensic Examinations and Examiners Victims of sexual assault may receive a sexual assault forensic examination by a medical provider who may or may not be a trained sexual assault forensic examiner. Medical providers assess victims’ clinical conditions; provide appropriate treatment and medical referrals; 8 State sexual assault coalitions of rape crisis centers, sexual assault service providers, and other organizations and individuals provide direct support to member rape crisis centers through funding; training and technical assistance; public awareness activities; and public policy advocacy. Page 5 GAO-16-334 Sexual Assault Exam Readiness and, given consent by the victim, collect forensic evidence through a sexual assault forensic examination that may follow steps and use supplies from a sexual assault evidence collection kit. Under its protocol for sexual assault forensic examinations, DOJ recommends that medical providers collect a range of physical evidence, which can include, but is not limited to, clothing, foreign materials on the body, hair (including head and pubic hair samples and combings), body swabs, and a blood or saliva sample for DNA analysis and comparison. 9 In addition, sexual assault forensic exams typically include documenting biological and physical findings such as cuts or bruises, either in writing or photographs, and a recording of a victim’s medical forensic history such as the time and nature of the assault. Once the exam is complete, medical providers preserve the collected evidence, which may include packaging, labeling, and sealing evidence collection kits and storing kits in a secure location. Medical providers typically perform such exams only for acute cases of sexual assault, such as in cases where the assault occurred within the previous 72 to 96 hours, when the physical and biological evidence on a person’s body or clothes is considered most viable. 10 DOJ, IAFN, and the American College of Emergency Physicians (ACEP) recommend that sexual assault forensic exams be performed by specially trained medical providers—or sexual assault forensic examiners (examiners). 11 These examiners include physicians, physician assistants, nurse practitioners, and other registered nurses who have been specially educated and completed clinical requirements to perform sexual assault forensic exams. Sexual assault nurse examiners (SANE) —a particular type of sexual assault forensic examiners—are registered nurses, including nurse midwives and other advanced practice nurses, who have received specialized education and have fulfilled clinical requirements to perform sexual assault forensic exams. Examiner programs have been created in hospital or non-hospital settings whereby specially trained 9 Department of Justice, A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents, NCJ 228119 (Washington, D.C.: U.S. Department of Justice, 2013). 10 The standard of practice for how long such evidence is viable changes as scientific advancements are made, with some jurisdictions now performing medical forensic exams up to 7 days after an assault. 11 Medical providers who have not received specialized training on how to perform sexual assault forensic exams may still perform exams. Page 6 GAO-16-334 Sexual Assault Exam Readiness examiners are available to provide first-response care and exams to sexual assault victims. Additionally, for pediatric victims, specially trained examiners may perform medical forensic exams in a child-specific facility, such as a child advocacy center. DOJ, IAFN, and some states have issued guidelines pertaining to the minimum level of training examiners should receive in order to properly collect and preserve evidence, identify victims’ medical and emotional health care needs, and provide counseling and referrals for victims. These guidelines include recommendations of objectives and topics that training programs should cover. For example, in their guidelines, DOJ and IAFN recommend that examiners receive comprehensive training that covers such topics as how to identify and deliver proper elements of a victim-centered sexual assault forensic examination where victims are fully informed of their options during and after the exam; how to assess patients and provide culturally competent medical care, including testing and delivery of prophylaxis for sexual transmitted infections and pregnancy; how to collect and document evidence in a way that protects the evidence’s integrity; how to testify about findings in court; and how to protect the chain of custody of evidence and coordinate care across a multidisciplinary team. 12 The goal of training, as outlined in the DOJ and IAFN guidelines, is for examiners to be able to effectively evaluate and address victims’ health concerns, minimize their trauma and promote their healing during and after the exam, and to detect, collect, preserve, and document physical evidence related to the assault for potential use by the legal system. In addition, registered nurses can become certified SANEs through IAFN to perform exams, though no such national certification exists for 12 See DOJ, National Training Standards for sexual Assault Examiners, NCJ 213827 (Washington, D.C.: June 2006); and International Association of Forensic Nurses, Sexual Assault Nurse Examiner (SANE) Education Guidelines (Elkridge, Md.: 2015). Page 7 GAO-16-334 Sexual Assault Exam Readiness examiners who are not registered nurses. 13 Depending on the state, examiners may also become certified through a state certifying body, such as a state board of nursing. There are no federal requirements concerning the training or availability of examiners in health care facilities outside of military, correctional, and Indian Health Service facilities. 14 While a Joint Commission accreditation 13 To be eligible to become a certified SANE to perform exams on adult or adolescent victims, nurses must have a minimum of 2 years of experience working full time as a registered nurse or a minimum of 3 years to be eligible to become certified to perform exams on pediatric victims. To become certified, nurses must also complete at least a 40hour training course in adult and adolescent sexual assault education; work under an expert, such as a SANE-certified nurse, and perform enough sexual assault exams to demonstrate clinical competency to this expert; and successfully pass a certification test. IAFN SANE certification lasts for 3 years. To become recertified, SANEs may either take the certification test again or obtain continuing education. The Commission on Forensic Nursing Certification, a functionally autonomous component of the IAFN, develops and administers SANE certification. 14 The Department of Defense has issued guidance for implementing its comprehensive policy for preventing and responding to sexual assault. The guidance specified roles, responsibilities, and training for personnel, such as health care providers, who may be involved in responding to victims of sexual assault. For example, DOD’s instruction identifies various types of health care providers who, depending on their training, may be eligible to conduct sexual assault forensic examinations. It also identified required categories of training for program personnel on topics that include the sexual assault examination process. Department of Defense, Sexual Assault Prevention and Response Program Procedures, Instruction 6495.02 (Washington, D.C.: March 28, 2013). Under the Prison Rape Elimination Act National Standards, correctional facilities are required to follow a uniform sexual assault forensic evidence collection protocol adapted from the DOJ’s National Protocol for Sexual Assault Forensic Examinations or similarly comprehensive and authoritative protocols developed after 2011. In addition, all victims of sexual assault must be offered access to a sexual assault forensic exam whether on-site or at an outside facility; and exams must be performed by a sexual assault forensic examiner or SANE if one is available. 28 C.F.R. pt. 115 (2015). The term “correctional facilities” refers to adult prisons and jails, lockups, community confinement facilities, and juvenile correctional facilities. Page 8 GAO-16-334 Sexual Assault Exam Readiness standard requires hospitals to establish policies for identifying and assessing possible victims of sexual assault and to train staff on those policies, each hospital is responsible for determining the level of specificity of such policies, including the minimum level of training required of its medical staff that perform exams. 15 Some states may have established minimum training requirements of nurses that perform sexual assault forensic exams and require nurses to become certified either through the IAFN or the state. Federal Grant Programs As authorized by VAWA, DOJ administers several grant programs that aim to, among other things, improve response to and recovery from four broad categories of victimization—domestic violence, sexual assault, dating violence, and stalking. The grant programs aim to address these categories of victimization through a range of activities, including public education and prevention; improved collaboration among stakeholders; training of law enforcement, prosecutors, court personnel, and victim service providers; strengthening victim services; developing and implementing more effective police, court, and prosecution policies and services; and improving data collection and communication systems related to these crimes. According to DOJ officials, there are three key VAWA authorized grant programs administered by DOJ’s Office on Violence Against Women (OVW) that can be used by grant recipients to fund or train sexual assault forensic examiners. In March 2011, the Indian Health Service within the Department of Health and Human Services implemented a new policy, through its Indian Health Manual, that all Indian Health Service-operated facilities must provide patients age 18 and older who present themselves for sexual assault services with access to an exam on-site or by referral. Victims who are referred elsewhere must be transported within 2 hours of the victim’s presentation at the medical facility. All registered nurses, advanced practice nurses, physicians, and physician assistants new to caring for adult and adolescent sexual assault patients must complete 40 hours of examiner training as well as clinical practice experience under the guidance of a forensically experienced medical provider. All examiner training and clinical practice experience must conform to the SANE educational requirements of the IAFN and the DOJ National Sexual Assault Medical Examining Training Standards. Department of Health and Human Services, Indian Health Service, “Chap. 29—Sexual Assault.” Pt. 3 in Indian Health Manual (Rockville, Md.: May 16, 2014). 15 The standard requires hospitals to establish a policy that includes a clear explanation of: (1) criteria for identifying victims of abuse and neglect; (2) the process for assessment and referrals; (3) education process (both orientation for new hires and annual education); and (4) the process for reporting this information internally and externally. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations in the United States. The Joint Commission, Provision of Care, Treatment, and Services, 2015 Hospital Accreditation Standards (Oakbrook Terrace, IL: 2015). Page 9 GAO-16-334 Sexual Assault Exam Readiness Services-Training-Officers-Prosecutors Violence Against Women Formula Grant Program (STOP Grant Program): The purpose of the STOP grant program, the largest of the three key grant programs, is to help states, courts, and local governments develop and strengthen effective law enforcement and prosecution strategies to combat violent crimes against women and to develop and strengthen victim services in cases involving violent crimes against women. Under the STOP grant program, there are 20 statutorily defined purposes for which funds may be used, one of which pertains directly to training examiners in the collection and preservation of evidence, analysis, prevention, and providing expert testimony and treatment of trauma related to sexual assault. The STOP Grant Program is a formula grant program in which all states and territories are awarded a minimum amount of $600,000 plus an additional amount based on state population size. 16 STOP Grant Program awards may support up to 75 percent of the costs of all projects, including the cost of administering those subgrants; the remaining 25 percent of costs must be covered by nonfederal match sources. 17 The average STOP grant award to states in fiscal year 2015 was about $2.5 million and ranged from roughly $600,000 to $13.2 million. Once states receive funds, a designated state agency—referred to as the state STOP administrator—is responsible for distributing funds to subgrantees based on the state’s own subgrant award process. 18 However, state STOP administrators must allocate funds according to a statutorily defined formula—that is, 25 percent of funds must be distributed for law enforcement, 25 percent for prosecutors, 30 percent for victim services, 5 percent to state and local courts, and 15 percent for discretionary distribution within the program purpose areas. We refer to STOP subgrantees as grantees throughout this report. 16 The term “state” includes the District of Columbia for purposes of this report. 17 For purposes of determining the state portion of matching funds, subgrants to victim service providers, as defined under VAWA, or tribal governments can be excluded from the total costs of the project. 18 In fiscal year 2014, STOP administrators were designated officials from state governmental agencies, such as governor’s offices, offices of the attorney general, or departments of justice, public safety, health, or social services. Page 10 GAO-16-334 Sexual Assault Exam Readiness Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest Grant Program): The purpose of the Arrest Grant Program is to encourage state, local and tribal governments and courts to treat domestic violence, dating violence, sexual assault, and stalking as serious violations of criminal law requiring the coordinated involvement of the entire criminal justice system. Eligible applicants include states, territories, and units of local government; Indian tribal governments; state, local, tribal, and territorial courts; victim service providers; state or tribal sexual assault or domestic violence coalitions; and government rape crisis centers. 19 For the Arrest Grant Program, at least 25 percent of appropriated funds must be allocated to activities that address sexual assault. Developing, implementing, or enhancing examiner programs, including the hiring and training of such examiners, is 1 of 22 purpose areas for which Arrest Program grant funding can be used. The average grant award in fiscal year 2015 was $601,361 and ranged from $224,668 to $900,000. Rural Sexual Assault Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural Grant Program): The purpose of the Rural Grant Program is to enhance the safety of rural victims of sexual assault, domestic violence, dating violence and stalking, and support projects uniquely designed to address and prevent these crimes in rural areas. At least 75 percent of total Rural Grant Program funding must be allocated to eligible entities in “rural states,” as defined by VAWA 2013. 20 Eligible entities include states, territories, Indian tribes, local governments, and nonprofit entities including tribal nonprofit organizations. In addition, at least 25 percent of funds appropriated for the Rural Grant Program must be allocated to 19 For the purpose of the Arrest Grant Program, the term “units of local government” is defined as any city, county, township, town, borough, parish, village, or other generalpurpose political division of a State. A “victim service provider” refers to nonprofit, nongovernmental or tribal organization or rape crisis centers, including a state or tribal coalition that assists or advocates for sexual assault, domestic violence, dating violence, or stalking victims. 20 Under VAWA 2013, the term “rural state” is defined as a state that has a population density of 57 or fewer persons per square mile or a state in which the largest county has fewer than 250,000 people, based on the most recent decennial census. 42 U.S.C. § 13925(a)(27). Based on this criteria, DOJ designated the following states as “rural states”: Alaska, Arizona, Arkansas, Colorado, Idaho, Iowa, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, Vermont, West Virginia, and Wyoming. Page 11 GAO-16-334 Sexual Assault Exam Readiness activities that address sexual assault in rural areas. Regardless of whether a grantee is from a rural or nonrural state, funds must be used for services and activities in a rural area or rural community. 21 Grantees are required to implement at least one of five statutorily defined strategies, one of which includes developing, enlarging, or strengthening programs addressing sexual assault, including examiner programs. The average grant award in fiscal year 2015 was $599,997 and ranged from $144,000 to $999,993. Across these three grant programs, a total of $186.7 million in funds was awarded to grantees in fiscal year 2015. (See table 1.) Table 1: Total Amount of Grant Awards from Three Department of Justice Grant Programs That May Be Used to Train or Fund Sexual Assault Forensic Examiners, Fiscal Year 2015 Grant program Total awards ($) Services-Training-Officers-Prosecutors (STOP) Violence Against Women Formula Grant Program $138,077,177 Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program $26,459,900 Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program $22,199,876 Total $186,736,893 Source: Department of Justice GAO-16-334 Notes: The total award amount includes awards to grantees in the 50 states, the District of Columbia, and the U.S. territories. Organizations that receive DOJ grant awards (or subgrant awards) through the STOP, Arrest, and Rural Programs are required to submit annual or biannual reporting forms to the OVW that include information about how they used grant funding, including specific information about whether funding was used to provide training for or fund sexual assault forensic examiners. 21 Under VAWA 2013, the terms “rural area” and “rural community” are defined as any area or community that is not within a designated standard metropolitan statistical area, as defined by the Office of Management and Budget; any area or community that is within or considered as part of a designated metropolitan statistical area and located in a rural census tract; or any federally recognized Indian tribe. Page 12 GAO-16-334 Sexual Assault Exam Readiness DOJ officials told us that funding from additional DOJ grant programs may be used to fund, train, or support the training of examiners, though officials stated that the use of such grant funding for these purposes is limited. Such programs include the Office for Victims of Crime’s Training and Technical Assistance Center and its National Sexual Assault TeleNursing Center demonstration project as well as the Bureau of Justice Assistance’s Byrne Justice Assistance Grant Program. In addition, OVW also administers the Technical Assistance Grant Program, which aims to provide direct technical assistance to existing and potential grantees to successfully implement projects supported by OVW grant funds. The Technical Assistance Program is aimed at providing in-person and online educational training opportunities, peer-to-peer consultations, site visits, and other types of tailored assistance to help grantees, including STOP, Arrest, and Rural Program grantees, implement grantfunded activities effectively. Although Technical Assistance Program providers could also use awarded funding to provide training that would help examiners to perform at a higher level of proficiency, DOJ officials noted that such providers do not provide comprehensive classroom or clinical training to medical providers aspiring to become an examiner. According to officials from HHS, as of September 2015, HHS did not administer any grant programs that are used to train or fund examiners nor has it issued guidance or requirements concerning the training of medical professionals on conducting exams or the availability of examiners. Although HHS was authorized through VAWA 2013 to administer the Consolidated Grants to Strengthen the Healthcare System’s Response to Domestic Violence, Dating Violence, Sexual Assault, and Stalking, funds were never appropriated to HHS for this program. 22 In addition, officials from both agencies told us that, as of September 2015, DOJ and HHS had not collaborated on any activities concerning the training of medical providers on conducting sexual assault forensic exams or the availability of trained examiners. 22 The program was authorized, among other things, to develop training for health professionals and comprehensive strategies to improve the response of hospitals, clinics, and other public health facilities to domestic violence, dating violence, sexual assault, and stalking. Page 13 GAO-16-334 Sexual Assault Exam Readiness Most States Had at Least One Grantee That Used Federal Grant Funds to Train or Fund Examiners In 49 states, at least one STOP, Arrest, or Rural Program grantee— including STOP subgrantees—reported using federal grant funds to provide training for sexual assault forensic examiners in 2013, the most recent year for which complete data were available. 23 Grantees used funds for a variety of examiner training activities. In addition to training examiners, grantees in 26 states funded examiner staff positions in 2013, although grantees in these states funded less than one full-time equivalent (FTE) examiner position, on average. Grantees in 49 States Used Federal Grant Funds to Provide a Variety of Training to Examiners in 2013 In nearly all states in 2013, at least one STOP, Arrest, or Rural Program grantee reported using federal grant funds to provide training for sexual assault forensic examiners in 2013. 24 Specifically, in 2013, approximately 227 grantees in 49 states reported using grant funds to provide training for over 6,000 examiners. 25 Most examiners (4,936) received training from STOP grantees. (See table 2.) However, on the basis of available data, it is unclear how many examiners received comprehensive examiner training versus other training that could help enhance their ability to serve victims. 26 23 We refer to STOP subgrantees as “grantees” and we use the term “states” to refer to the 50 states and the District of Columbia for purposes of this report. 24 Grantees may provide training for examiners either directly or by funding training provided by other entities. 25 Because the number of Arrest and Rural grantees can differ between reporting periods within the same year, the total number of grantees is equal to the sum of the number of STOP grantees that provided training in 2013 plus the average number of Arrest grantees and the average number of Rural grantees that used grant funds for this purpose in the two reporting periods in 2013 (January through June 2013 and July through December 2013). The total number of examiners who received training from STOP, Arrest, and Rural Program grantees may include some duplication. DOJ officials told us that examiners are counted once for each grant program and once for each reporting period that they receive training. But, an examiner may receive training through multiple grant programs or in multiple reporting periods. 26 In the context of grantee progress reports, DOJ defines “training” as providing information on sexual assault, dating violence, domestic violence, and stalking that enables professionals to improve their response to victims/survivors as it relates to their role in the system. DOJ does not collect information on the number of medical providers who were specifically trained to become sexual assault forensic examiners. Page 14 GAO-16-334 Sexual Assault Exam Readiness Table 2: Number of Sexual Assault Forensic Examiners Who Received Training Provided by Grantees, 2013 Grant program Reporting period Examiners who received training Services-Training-Officers-Prosecutors (STOP) Violence Against Women Jan. – Dec. 2013 Formula Grant Program Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest) Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural) Jan. – June 2013 462 July – Dec. 2013 512 Jan. – June 2013 185 July – Dec. 2013 Estimated Total a 4,936 97 6,192 Source: Department of Justice (DOJ) GAO-16-334 Notes: Data presented are from grantees in the 50 states and the District of Columbia. The term “grantees” includes STOP subgrantees. In the context of grantee progress reports, DOJ defines training as providing information on sexual assault, domestic violence, dating violence, and stalking that enables professionals to improve their response to victims. The training that grantees provided for examiners includes but is not limited to comprehensive training to perform sexual assault forensic exams. It also could include continuing education training or training on individual topics, such as testifying in court, that enable examiners to improve their response to victims. a The estimated total number of examiners who received training from STOP, Arrest, and Rural Grant Program grantees may include some duplication. DOJ officials told us that examiners are counted once for each grant program and for each reporting period that they receive training. For example, one examiner may receive training through multiple grant programs or in multiple reporting periods. Based on interviews with grantees in some of our six selected states and a review of grantee progress reports submitted to DOJ in 2013, the type of training that grantees provided for examiners ranged from comprehensive examiner training and certification to training on specific topics that enable examiners to improve their response to victims. Grantees reported using federal grant funds to provide examiners with the following types of training: • Comprehensive Examiner Training or Certification: Grantees reported using funds to provide comprehensive examiner training that, for example, included 40 or more hours of classroom training as well as, in some cases, clinical practice training. For example, in 2014, a Wisconsin grantee used STOP grant and state budget funds to provide five 40-hour training courses and three clinical skills labs for examiners, training a total of 115 new examiners. Although the state neither offers nor requires examiner certification, those that participated in the training could become certified through IAFN. In addition, the statewide examiner training program in Colorado, which is partially supported using STOP grant funds, both trained and certified 74 new examiners in 2014. Page 15 GAO-16-334 Sexual Assault Exam Readiness • Examiner Recertification or Continuing Education Training: In addition to comprehensive examiner training or certification, some grantees used grant funds to offer periodic recertification or “refresher” training so that examiners can maintain competency. For example, a grantee in Kansas provided refresher training to examiners who were identified by forensic lab evaluation forms as having errors in evidence collected through sexual assault forensic exams. • Topical Training: Some grantees reported providing training to examiners on specific topics, such as interviewing and photography techniques, court room testimony, or victim confidentiality protocols. For example, officials from the statewide examiner training program in Colorado told us that in the past they have used both STOP and Arrest Program funds to provide courtroom training for examiners. Other grantees reported providing training to examiners on working with certain types of victims, such as lesbian, gay, bisexual, transgender, disabled, or elderly victims. The extent of examiner training efforts supported with STOP, Arrest, and Rural Grant Program funds varied by state. In 2013, the total number of examiners who received training funded through these grant programs in each state ranged from 0 to 604. In half of the states (26), fewer than 100 examiners received training and in 12 of these states fewer than 25 examiners received training. (See figure 1.) Further, based on interviews with grantees in selected states, we found that while some grantees used funds to support statewide comprehensive examiner training programs, other grantees used funds to provide training in specific locations, such as a single county or hospital. For example, at least one grantee each in Colorado, Florida, Massachusetts, and Wisconsin used STOP or Arrest Program funds, in combination with other funding, to support statewide comprehensive examiner training programs. However, Jefferson County in Oregon used its Rural Program funds for one examiner’s recertification as well as other continuing education training for four examiners at a local hospital in 2014. Additionally, the Colorado Sexual Assault Response Project used Arrest Program funds to provide training for 44 examiners in rural areas to perform exams. The number of grantees in each state that used grant funds to provide training for examiners also varied. For example, in 2013, the number of grantees that reported providing training for examiners per state ranged from 0 to 19. While 12 grantees provided training for a total of 43 examiners in North Carolina, two grantees provided training for a total of 347 examiners in Illinois in 2013. (For more detailed information on the number of grantees that reported providing Page 16 GAO-16-334 Sexual Assault Exam Readiness training for examiners and the number of examiners provided training in each state by grant program, see appendix I.) Figure 1: Number of Sexual Assault Forensic Examiners Who Received Training Provided by Federal Grantees in 2013, by State Notes: The term “grantees” includes STOP subgrantees. Page 17 GAO-16-334 Sexual Assault Exam Readiness Some entities used funds from DOJ’s Technical Assistance Program to provide training for examiners on a national scale. DOJ officials told us that although OVW does not fund any Technical Assistance Program award recipients to provide classroom or clinical training for examiners, some may provide national training that assists examiners in developing knowledge, experience, or skills to perform at a higher level of proficiency. For example, in 2014 IAFN used Technical Assistance Program funds to provide online and in-person training for examiners on topics such as treating transgender victims of sexual assault and payment policies for forensic exams. In the reporting period January through June 2014, Technical Assistance Program award recipients provided training for 1,772 examiners. DOJ officials told us that the majority of these examiners (1,609) received training provided by five Technical Assistance Program award recipients. 27 DOJ officials told us that the STOP, Arrest, and Rural grant programs are the key grant programs from which funds are available to train examiners, though grantees may use funds to address four broad categories of victimization—sexual assault, domestic violence, dating violence, and stalking. Further, within the category of sexual assault, there is an extensive range of issue areas that grantees can choose to address, including providing training for examiners. For example, grantees may choose to use funds to pay for victim services or to train other professionals, such as law enforcement officers, judges, and prosecutors, on issues related to sexual assault. Of all STOP, Arrest, and Rural Program grantees, 8.4 percent reported using grant funds specifically to provide training for examiners in 2013. According to DOJ and state officials, grantees might not use STOP, Arrest, or Rural Grant Program funds to provide training for examiners for a variety reasons, including competing demands for the use of funds and a lack of competitive grant applications from entities seeking funds for this purpose. For example, officials in Florida reported that STOP grant funds are not used to provide training for examiners but are instead targeted 27 Given DOJ data collection methods and its definition of “training,” we cannot determine specifically what type of training these examiners received. However, DOJ officials told us that, in general, the five Technical Assistance Program grantees that reported providing training for examiners provided web-based and in-person training on topics such as: sexual assault forensic exams; law enforcement response to sexual assault; working with child victims of sexual abuse; working with transgender victims; and victim-centered responses in cases with unsubmitted and backlogged rape kits. Page 18 GAO-16-334 Sexual Assault Exam Readiness towards other areas, such as law enforcement, victim services, or developing and supporting sexual assault response teams. 28 DOJ officials and state STOP administrators also told us that not all grant applications seeking funds to train examiners may be approved. For example, DOJ officials told us that grant applications may be denied if they do not meet the standardized criteria OVW uses in the review of applications for the Arrest and Rural programs or, despite meeting OVW’s criteria and scoring well, other applications score better. 29 Additionally, officials told us that it is possible that few applicants seek funding to train examiners. For example, the Nebraska STOP Administrator told us that due to a lack of knowledge that grant funds can be used for this purpose, the state received only one application to train examiners, which was not approved due to competing demands for available funds. Some grantees in our six selected states that did not use STOP, Arrest, or Rural Grant Program funds to provide training for examiners used other funds, such as funds from state and hospital budgets or nonprofit organizations, to train examiners. In Nebraska, for example, examiner training is primarily funded by a hospital system that also employs over half of the examiners in the state (24 out of 43 examiners). Although Oregon did not use federal funds to provide training for examiners, officials told us that the Oregon Sexual Assault Task Force, a statewide nonprofit organization, uses grant funds from the state department of justice to offer 40-hour comprehensive examiner training courses two times per year. Finally, some grantees told us that they used federal grant funds to provide sexual assault exam overview training for health and other professionals. For example, one grantee in Massachusetts told us 28 Sexual assault response teams are multidisciplinary teams that provide specialized and immediate response to victims of sexual assault. Although the composition of these response teams varies across communities, they typically include health care personnel (including sexual assault forensic examiners), law enforcement representatives, community-based victim advocates, prosecutors, and forensic scientists. 29 OVW uses a standardized peer-review process to score grant applications against criteria set forth in the grant solicitation. Criteria include, for example, whether activities would put victims at risk, whether activities fall outside of the scope of the grant program, and how well applicants describe the proposed goals, activities, and expertise of and partnerships with other organizations involved in the project. In addition, DOJ officials told us that applicants might be denied based on geographic variability. For example, 75 percent of Rural Grant Program funds must be awarded to applicants in rural states; as a result, a strong application might be denied because it is from a non-rural state and there are not enough funds left for approval. Page 19 GAO-16-334 Sexual Assault Exam Readiness that they used grant funds to provide basic forensic evidence collection training to staff at hospitals that did not have trained examiners available. Grantees in 26 States Funded Examiner Positions in 2013, and Grantees in These States Funded Less Than One Position on Average In half of the states, at least one STOP, Arrest, or Rural grantee funded examiner staff positions in 2013. Approximately 75 grantees in 26 states funded roughly 50 FTE examiner positions in 2013, most of which (46 FTE examiner positions) were funded by STOP grantees. 30 (See table 3). In these 26 states, grantees funded, on average, less than one FTE examiner position each, ranging from 0.1 to 9.8 FTEs in 2013. Further, few STOP, Arrest, or Rural grantees used funds to pay for FTE examiner positions in 2013. In 2013, approximately 2.5 percent of STOP grantees, 5.2 percent of Arrest grantees, and 6.3 percent of Rural Program grantees reported using grant funds for FTE examiner positions. Table 3: Number of Full-time Equivalent (FTE) Sexual Assault Forensic Examiner Positions Funded by Grantees, 2013 Reporting period FTE examiner a positions funded Services-Training-Officers-Prosecutors (STOP) Violence Against Women Formula Grant Program Jan. – Dec. 2013 46.0 Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest) Jan. – June 2013 3.3 July – Dec. 2013 2.0 Jan. – June 2013 2.6 Grant program Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural) July – Dec. 2013 Estimated Total b 1.4 50.6 Source: Department of Justice (DOJ) GAO-16-334 Notes: Data presented are from grantees in the 50 states and the District of Columbia. The term “grantees” includes STOP subgrantees. 30 The total number of grantees represents the number of STOP grantees that funded examiner positions in 2013 plus the average number of Arrest grantees and the average number of Rural grantees that funded examiner positions in the two reporting periods for 2013 (January to June 2013 and July to December 2013). Similarly, the number of FTE examiner positions funded represents the number of positions funded by STOP grantees in 2013 plus the average number of positions funded by Arrest grantees and the average number funded by Rural grantees in the two reported periods. Grantees report the number of FTE examiner positions funded rather than the number of examiners that they hired. According to DOJ, one FTE may represent one full-time staff person or the equivalent of 40 hours per week divided among more than one staff person performing the same function. Page 20 GAO-16-334 Sexual Assault Exam Readiness a For the STOP Grant Program, one FTE is equal to 40 hours of work for 52 weeks. For the Arrest and Rural Grant Programs, one FTE is equal to 40 hours of work for 26 weeks. DOJ officials told us that while it is possible to aggregate FTEs across grant programs for a single reporting period, it is not possible to aggregate FTEs across reporting periods. b The estimated total number of FTE examiner positions funded represents the sum of the number of FTE examiner positions funded by STOP grantees in 2013 plus the average number of FTE examiner positions funded by Arrest grantees and the average number funded by Rural grantees in the two reporting periods in 2013 (January through June 2013, and July through December 2013). Information from interviews with officials in two of our six selected states suggests that grantees that fund examiner positions may fund an examiner to act as an examiner program coordinator. Program coordinator duties may include overseeing the operations of examiner programs, training examiners, providing technical assistance, and providing forensic exams. For example, officials in both Massachusetts and Wisconsin told us that STOP Grant Program funds were used to pay for a statewide coordinator in FY 2014. In addition, grantees also used grant funds to pay for examiners to be on-call. For example, a grantee in Hawaii reported that STOP grant funding allowed them to provide on-call pay to examiners in the state. Nationwide Data on the Availability of Sexual Assault Forensic Examiners Are Limited; Officials in Selected States Reported a Need for Additional Examiners According to our literature review and the experts we interviewed, only limited nationwide data exist on the availability of sexual assault forensic examiners—that is, both the number of practicing examiners and health care facilities that have examiner programs. While IAFN reported that, as of September 2015, there were 1,182 nurses with active IAFN SANE certification in the United States, such data do not represent all practicing examiners nationwide. For example, the data do not account for examiners who completed training through an IAFN or a state training program but never became certified or were certified through another entity, such as a state board of nursing. IAFN also collects data on examiner programs nationwide—that is, data on hospitals, clinics, and other sites where examiners practice. Such data provide an indication of the availability of examiners, but the data are also limited. While 703 examiner programs nationwide voluntarily reported to IAFN’s examiner program database, as of September 2015, IAFN officials noted that the database is often not up-to-date and some health care settings where sexual assault forensic exams are conducted, such as child advocacy centers, are not represented. In addition, data collected on staffing characteristics of examiner programs are often unavailable in the IAFN examiner program database. For example, only about one-third of the examiner programs reported on the number of examiners practicing in their program and about one-third reported on whether examiners were available on-site versus on-call. Page 21 GAO-16-334 Sexual Assault Exam Readiness In three of six selected states, STOP administrators or officials from sexual assault coalitions were able to provide estimates of the number of practicing examiners and, in all six states, they were able to provide information on the estimated number of examiner program locations in their state. 31 Of states that reported, the number of practicing examiners and examiner programs varied by state. (See table 4.) However, such data may also present an incomplete picture of the availability of examiners. For example, only one of the six selected states has a system in place to formally track the number and location of examiners. Instead, officials generally reported on the estimated number of examiners or examiner locations that were part of a statewide examiner program or were identified through an ad hoc data collection effort. Table 4: Estimated Number of Practicing Sexual Assault Forensic Examiners and Examiner Programs in Selected States, As of January 2016 Estimated number of practicing examiners Estimated number of examiner program locations Colorado Not Available 23 Florida Not Available State Massachusetts Nebraska b Oregon Wisconsin 141 61 140 Not Available 15 a 29 7 12 c 18 Source: GAO analysis of state data GAO-16-334. Notes: a The reported number of examiner programs is limited to those located in certified rape crisis centers in Florida. It does not include examiner programs that are located in other facilities, such as hospitals. b Data presented for Nebraska does not account for examiners who may be located in child advocacy centers. There are seven child advocacy centers in Nebraska that provide sexual assault forensic exams, including to adult victims. c One of the 12 examiner programs is a mobile examiner program that serves five counties in Oregon. 31 Some coalition officials we interviewed in selected states also told us that information on the availability of bilingual examiners is not available. Anecdotally, however, these officials told us that no or few bilingual examiners are available and instead, where available, interpreters or interpreter services are used when providing exams to non-English speaking victims. Page 22 GAO-16-334 Sexual Assault Exam Readiness Although data are limited, STOP administrators and sexual assault coalition officials in all six selected states nevertheless told us that the number of examiners available does not meet the need for exams within their states. For example, coalition officials in Wisconsin told us that nearly half of all counties in the state do not have any examiner programs available, and coalition officials in Nebraska told us that most counties in the state do not have examiner programs available. In addition, in four of six selected states—Colorado, Florida, Nebraska, and Wisconsin—state STOP administrators and coalition officials told us that few or some health care facilities in their state have examiners available. 32 As a consequence, officials said victims may need to travel long distances to be examined by a trained examiner or be examined by a medical professional without specialized training. For example, the Colorado STOP administrator explained that although there is an examiner program available in all regions of the state, not all hospitals participate in Colorado’s statewide examiner program. As a result, in the rural Western region of Colorado, for example, victims may have to travel more than an hour to reach a facility with examiners available. While in the other two selected states—Massachusetts and Oregon—state STOP administrators and coalition officials stated that some or most facilities have examiners available, they noted that there is still a need for additional capacity to reduce the burden on those examiners who are available or to make examiners available in a number of areas where examiners are currently unavailable. For example, Massachusetts coalition officials told us that there is an ongoing need for examiners across the state. There were few or in some cases no examiners available in rural areas, according to state STOP administrators or coalition officials we interviewed in selected states. STOP administrators and coalition officials in Colorado, Florida, and Wisconsin told us that in rural areas there may be only one examiner or one examiner program available across multiple counties. For example, Colorado coalition officials told us that of the five rural counties in Central Colorado, only one county had an examiner available. Alternatively, according to the Nebraska STOP administrator, some victims might have to travel to a major metropolitan area to reach a facility with examiners available, which could take 2 or more hours. In general, state STOP administrators and coalition officials explained that it 32 The Wisconsin STOP administrator noted, however, that most facilities in urban areas have examiners available. Page 23 GAO-16-334 Sexual Assault Exam Readiness could take a victim 30 minutes or less in urban areas to up to 2 hours in rural areas to reach a facility that has an examiner available. STOP administrators and coalition officials we interviewed explained that the availability of examiners in rural areas is challenging for a number of reasons, including the limited availability of health care providers generally, weather-related travel restrictions that can affect the time and distance victims must travel to reach a facility with an examiner, difficulty recruiting qualified nurses to undergo training, and a lack of capacity in rural areas to provide examiner training opportunities. 33 Even in some urban areas the availability of examiners may be limited, according to state STOP administrators or coalition officials we interviewed. For example, Wisconsin coalition officials explained that just one of the five major hospitals in Milwaukee has examiners available, and some victims may be unwilling to travel to that hospital to receive an exam from an examiner. In addition, Florida coalition officials told us that even in urban areas there are only a few specialized places where victims can receive an exam from a trained examiner. In health care facilities where examiners are available, they are typically available through hospitals on an on-call basis, according to literature we reviewed as well as all STOP administrators and coalition officials we interviewed. 34 Results from a 2005 national survey of examiner programs showed that most programs (60 percent) were administered through hospitals and 71 percent of examiner programs used staffed examiners on a part-time, on-call basis. 35 According to literature we reviewed as well 33 On the basis of literature we reviewed as well as STOP administrators or coalition officials we interviewed in Oregon and Wisconsin, the use of mobile examiner programs improves the availability of examiners in rural areas. For example, the West Virginia Regional Mobile SANE program was implemented in 2004 whereby a pool of examiners provide on-call coverage 24 hours, 7 days a week to four hospitals within a four-county region of the state. 34 According to literature we reviewed and the STOP administrators and coalition officials we interviewed, examiners are also available in other settings, such as rape crisis centers, community health centers, and criminal justice agencies, though to a lesser extent. Most examiners trained to perform exams on pediatric victims are available through child advocacy centers, according to state STOP administrators and coalition officials in six selected states. 35 T. K. Logan, J. Cole, and A. Capillo, “Sexual Assault Nurse Examiner Program Characteristics, Barriers, and Lessons Learned,” Journal of Forensic Nursing vol. 3, no. 1 (2007). Page 24 GAO-16-334 Sexual Assault Exam Readiness as experts and Colorado, Florida, and Oregon coalition officials we interviewed, on-call examiners may serve “dual roles”—that is, they simultaneously work as emergency department nurses and cover their on-call examiner shift. Specifically, results from the 2005 survey showed that about one-quarter of all examiner programs used nurses who overlapped their emergency department shifts with their on-call examiner shifts. 36 Alternatively, according to the STOP administrators in Colorado and Oregon, examiners in some facilities or rural areas may not work based on an official on-call schedule. Instead, an examiner program coordinator will call through a list of examiners practicing in a region of the state when a victim arrives to find an examiner available to conduct the exam. The Colorado STOP administrator noted, however, that it is often the case that no examiners are available and the coordinator, who is also a trained examiner, will ultimately come in to the hospital to perform the exam instead. In addition, among facilities that have examiners available, the number of examiners available varies and may not provide enough capacity for facilities to offer examiner coverage 24 hours, 7 days a week, according to state STOP administrators and coalition officials we interviewed. Nebraska coalition officials, for example, told us that while one hospital in Omaha has a team of 26 examiners available, other facilities in the state may have as few as three examiners available. Further, Florida coalition officials and the Colorado STOP administrator told us that there are few facilities in their states able to offer full coverage with examiners available 24 hours, 7 days a week. For example, Memorial Hospital in Colorado Springs is the only facility in Colorado that has enough examiners available to provide examiners on-staff 24 hours a day, 7 days a week, according to Colorado officials we interviewed. Staff from a rural hospital in Oregon explained that although it has two on-call examiners and one additional examiner available if needed, there are not enough examiners available to provide on-call coverage 24 hours, 7 days a week. According to state STOP administrators and coalition officials we interviewed in six selected states, health care facilities may have their own protocols in place concerning the expected response time of on-call examiners, transferring victims to facilities that have examiners available, and paging on-call examiners. Florida coalition officials as well as the 36 Logan et al., “Sexual Assault Nurse Examiner Program Characteristics,” 24. Page 25 GAO-16-334 Sexual Assault Exam Readiness Massachusetts and Oregon STOP administrators told us, for example, that facilities with examiners available may have an agreement in place that specifies the expected response time of examiners. State STOP administrators or coalition officials we interviewed in five of six selected states told us that, in general, examiners are expected to arrive at a facility within 30 minutes to 1 hour of being paged in urban areas, though it could take longer in rural areas. Some STOP administrators or coalition officials in selected states informed us that facilities that do not have examiners available may transfer or encourage victims to go to another facility with examiners available, or they may be treated by an untrained medical professional. One coalition official noted that victims who are referred elsewhere for exams often do not follow through and thus never receive an exam. This may be because, according to Florida coalition officials, victims may be responsible for transporting themselves or they may be transported on a case-by-case basis by law enforcement. Last, officials told us that the timing of when on-call examiners are paged varies. For example, Colorado and Florida officials told us that, if a victim is being transported to another hospital, the destination facility may not page the on-call examiner until the victim has arrived. However, officials from one hospital in rural Oregon and Wisconsin coalition officials explained that, in their states, local law enforcement will notify the destination hospital when a victim is being transported to their hospital so that an examiner can be paged in advance. Selected States Faced Challenges Training Examiners, Maintaining Stakeholder Support, and Retaining Examiners According to state STOP administrators and state sexual assault coalition officials we interviewed in six selected states, maintaining a supply of trained examiners that meets communities’ needs for exams is challenging for multiple reasons, including the limited availability of training, a lack of technical assistance and other resources, weak stakeholder support for examiners, and low examiner retention. In order to address these challenges, state officials told us that they have employed a variety of strategies, such as offering web-based training courses or clinical guidance or support for examiners, clinical practice labs, mentorship programs, and developing multidisciplinary teams within communities that respond to cases of sexual assault. Limited availability of training. Officials in five of six selected states told us that the limited availability of classroom, clinical, or continuing education training is a barrier to maintaining a supply of trained examiners. Regarding classroom training, some officials told us that training may only be offered once per year in their states. Additionally, officials from both Florida and IAFN told us that there is a need for Page 26 GAO-16-334 Sexual Assault Exam Readiness qualified instructors to run training sessions. Experts and officials from Colorado, Nebraska, and Oregon also told us that medical professionals in rural areas may have difficulty completing the clinical training necessary to become an examiner. Obtaining clinical experience, such as performing exams under the supervision of a trained examiner, is a particular challenge in rural areas where hospitals may treat only a few sexual assault cases per year. One official in Nebraska told us that trained examiners in rural areas might not feel competent to perform exams due to the low number of cases they treat. A lack of continuing education opportunities may also pose a challenge for examiners in maintaining the skills necessary to perform exams. For example, the National Sexual Violence Resource Center (NSVRC) reported that, based on common challenges identified through a survey of and group discussions among examiner program coordinators, maintaining competency may be difficult for nurses in rural areas due to a low volume of patients presenting in need of exams and limited access to ongoing and advanced training. 37 Officials told us that they have been able to increase the availability of examiner training through alternative training methods such as webbased training courses and simulated clinical training. For example, officials in Colorado told us that their state’s web-based examiner training program has made training less expensive and has increased examiner recruitment. Officials in Wisconsin told us that they developed a clinical training lab that allows examiners to gain hands-on experience by performing elements of exams on models who are experienced teaching assistants and hired for the purpose of training new examiners. Further, in 2014, a DOJ-funded evaluation of examiner training programs found that a web-based training course may help increase the availability of trained examiners; the study also found that implementing web-based training had benefits such as decreasing the costs associated with attending inperson training, expanding training opportunities to remote areas, and allowing examiners to be trained by national experts. 38 37 National Sexual Violence Resource Center, First National SANE Coordinator Symposium: Final Report and Recommendations (Portland, Oregon, 2009). 38 D. Patterson, S. Resko, J. Pierce-Weeks, and R. Campbell, Delivery and Evaluation of Sexual Assault Forensic (SAFE) Training Programs, Doc. No. 247081 (Washington, D.C.: Department of Justice, June 2014). Page 27 GAO-16-334 Sexual Assault Exam Readiness Lack of technical assistance and other supportive resources. Officials in four of six selected states told us that the limited availability of technical assistance and other supportive resources for examiners poses a challenge to maintaining a supply of trained examiners. For example, officials in Florida, Nebraska, Oregon, and Wisconsin explained that, in general, there is a lack of mentorship opportunities and leadership within the examiner community. Officials also noted that the sustainability of examiner programs may be threatened by a lack of internal capacity, such as not having a full-time, paid examiner program coordinator available. Further, in its survey of and group discussions with examiner program coordinators, NSVRC found that examiners and examiner programs needed technical assistance and support in the following areas: aspects of performing exams, training, leadership development and policy issues, and examiner program sustainability. 39 Specifically, examiners needed technical assistance and support on topics such as testifying in court; professional development; performing certain types of procedures, such as a colposcopy or anogenital photography; and working with special populations. Officials we spoke to told us about strategies that can be used to increase support for examiners and examiner programs, such as offering webbased technical assistance. For example, officials in Massachusetts told us that through their National Sexual Assault TeleNursing Center, trained SANEs provide remote clinical guidance to two hospitals in the state that do not have trained examiners available. 40 In addition, officials from Colorado told us that an examiner program coordinator in an urban hospital in the state provides volunteer on-call technical assistance and clinical guidance to examiners in rural parts of the state, where those resources are not otherwise available. Further, one study we reviewed found that several states were engaged in promising practices to increase support for examiners, such as implementing state-wide mentorship programs, developing regional examiner list-serves and online discussion 39 National Sexual Violence Resource Center, First National SANE Coordinator Symposium. 40 The National Sexual Assault TeleNursing Center is funded by the DOJ Office of Justice Programs, Office for Victims of Crime, and is aimed at providing live access to expert medical forensic examiners via telemedicine. Page 28 GAO-16-334 Sexual Assault Exam Readiness boards, creating formal leadership positions with in the examiner community, and requiring examiner program evaluations. 41 Weak stakeholder support for examiners. Officials in five of six selected states told us that limited stakeholder support for examiners and examiner programs, such as from hospitals and law enforcement, is a challenge to maintaining a supply of trained examiners. Some officials told us that hospitals may be reluctant to support examiners and examiner programs due to a low number of sexual assault cases treated each year. As a result, medical professionals may have to cover the cost of their examiner training courses themselves, including their travel and lodging expenses, and face lost wages associated with attending training. One official told us that hospitals may be reluctant to send nurses to examiner training as it takes away from their regular shift availability. Additionally, some hospitals do not pay examiners to be on-call. Officials in three states told us that hospitals typically either do not pay examiners to be on-call or pay on-call examiners significantly less than other on-call medical professionals. For example, one official in Wisconsin estimated that some examiners in their state receive between $1.00 and $1.50 per hour when on-call while others are not paid for on-call time. Officials from the American Hospital Association, when asked about whether they have developed any requirements, policies, or protocols concerning the training of or access to examiners in hospitals, told us that the association has not produced any information in this area. Apart from hospital support, officials in Colorado and Oregon explained that there is a need for more multidisciplinary support for examiners, such as increased law enforcement, prosecutor, and first responder understanding of examiners’ role. The literature we reviewed also shows that ambiguity around the role of the examiner in responding to sexual assault, may be a source of conflict between examiners and other 41 National Sexual Violence Resource Center, First National SANE Coordinator Symposium. Page 29 GAO-16-334 Sexual Assault Exam Readiness professionals. 42 For example, examiners were found to have experienced instances where victim advocates or law enforcement questioned examiners’ medical decisions, speed of evidence collection, or asked examiners to comment on the credibility of a victim’s case. One nationally representative survey of examiner programs found that examiner program coordinators felt that ongoing education of community stakeholders on sexual assault and examiner programs was needed due to high turnover in staff at relevant community institutions and agencies, such as law enforcement officers, victim advocates, and prosecutors. 43 Through our interviews with officials, we learned of strategies that selected states have used to increase or mitigate limited stakeholder support for examiners and examiner programs. For example, officials in Colorado, Florida, Nebraska, Oregon, and Wisconsin told us that sexual assault response teams have been developed in their states to help community stakeholders to understand examiners’ role and better coordinate to meet the medical and legal needs of sexual assault victims. Further, a 2005 nationally representative survey of examiner program coordinators found that some programs addressed limited stakeholder support for examiner training by negotiating with employers to count training as paid work. 44 Officials in Colorado also suggested that one strategy to mitigate limited hospital support for examiners would be to partner with non-hospital facilities such as health clinics that might support examiner programs. Low examiner retention rates. Officials in four of six selected states told us that low examiner retention rates can be an impediment to maintaining a supply of trained examiners. In addition to the challenges of limited training opportunities, technical assistance and other supportive resources, and stakeholder support for examiners, the physically and 42 See, for example, R. Campbell, M. Greeson, and D. Patterson, “Defining the Boundaries: How Sexual Assault Nurse Examiners (SANEs) Balance Patient Care and Law Enforcement Collaboration,” Journal of Forensic Nursing vol. 7, no. 1 (2011); J. Cole and T.K. Logan, “Negotiating the Challenges of Multidisciplinary Responses to Sexual Assault Victims: Sexual Assault Nurse Examiner and Victim Advocacy Programs,” Research in Nursing & Health vol. 31, no. 1 (2008); and S. L. Maier, “Sexual Assault Nurse Examiners’ Perceptions of Their Relationship with Doctors, Rape Victim Advocates, Police, and Prosecutors,” Journal of Interpersonal Violence vol. 27, no. 7 (2012). 43 Logan et al., “Sexual Assault Nurse Examiner Program Characteristics,” 24. 44 Logan et al., “Sexual Assault Nurse Examiner Program Characteristics,” 24. Page 30 GAO-16-334 Sexual Assault Exam Readiness emotionally demanding nature of examiner work contributes to low examiner retention rates. Further, studies have indicated that dissatisfaction with compensation, long work hours, and lack of support, among other things, may contribute to examiner burnout. Examiners typically work on-call in addition to their full time jobs as, for example, emergency department nurses. Officials in Florida told us that examiners may be on-call for 6-hour, 12-hour, or even 24-hour shifts. Further, one survey of examiner programs in Maryland found that examiners were required to be on-call for an average of 159 hours per month. 45 Wisconsin officials estimated that although 540 SANEs were trained over a 2-year period, only 42 (less than 8 percent) were still practicing in the state at the end of those 2 years. In addition, the 2005 survey of examiner program coordinators found that nearly two-thirds believed that examiner staffing, generally, was a challenge and nearly a third believed that SANE retention was a challenge. 46 Agency Comments We provided a draft of this report to DOJ for review. DOJ provided technical comments that we incorporated as appropriate. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the appropriate congressional committees, the Attorney General of the United States, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. 45 Maryland Coalition Against Sexual Assault, The State of the State: Sexual Assault Forensic Examiner (SAFE) Programs in Maryland (Arnold, Md.: 2012). 46 Logan et al., “Sexual Assault Nurse Examiner Program Characteristics,” 24. Page 31 GAO-16-334 Sexual Assault Exam Readiness If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or IritaniK@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Katherine M. Iritani Director, Health Care Page 32 GAO-16-334 Sexual Assault Exam Readiness Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training The following three tables show the number of grantees that used funding to provide training for examiners and the number of examiners who received training by federal grant program and state in 2013 and, where available, 2014. Table 5: Total Number of Services-Training-Officers-Prosecutors (STOP) Violence Against Women Formula Grant Program Grantees that Provided Training for Sexual Assault Forensic Examiners, and Total Number of Examiners Who Received Training by State, 2013 January – December 2013 State United States Number of STOP grantees that provided training for examiners Number of examiners who received training provided by STOP grantees 190 4936 AK 0 0 AL 3 71 AR 1 1 AZ 2 3 CA 4 439 CO 5 119 CT 0 0 DC 1 22 DE 1 66 FL 3 79 GA 2 38 HI 4 16 IA 4 402 ID 2 2 IL 2 347 IN 8 273 KS 1 50 KY 2 174 LA 0 0 MA 1 180 MD 2 42 ME 3 109 MI 5 112 MN 9 176 MO 4 101 Page 33 GAO-16-334 Sexual Assault Exam Readiness Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training January – December 2013 State Number of STOP grantees that provided training for examiners Number of examiners who received training provided by STOP grantees 2 101 MS MT 0 0 NC 11 30 ND 5 114 NE 1 10 NH 5 158 NJ 2 14 NM 2 24 NV 0 0 NY 17 439 OH 5 103 OK 4 47 OR 0 0 PA 18 86 RI 1 15 SC 7 119 SD 2 2 TN 2 16 TX 8 229 UT 4 60 VA 7 157 VT 0 0 WA 6 46 WI 6 300 WV 3 33 WY 3 11 Source: Department of Justice GAO-16-334 Note: The term “grantee” is used to refer to STOP subgrantees. Page 34 GAO-16-334 Sexual Assault Exam Readiness Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training Table 6: Total Number of Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest) Grantees that Provided Training for Sexual Assault Forensic Examiners, and Total Number of Examiners Who Received Training by State, 2013 and 2014 Number of Arrest grantees that provided training for examiners Number of examiners who received training from Arrest grantees January to June 2013 July to December 2014 January to June 2014 21 22 11 462 512 346 AK 0 0 0 0 0 0 AL 0 0 1 0 0 16 AR 0 0 0 0 0 0 AZ 1 0 0 22 0 0 CA 0 0 0 0 0 0 CO 1 1 1 2 21 17 CT 0 1 0 0 3 0 DC 0 1 0 0 16 0 DE 0 0 0 0 0 0 FL 2 2 1 68 81 4 GA 0 0 0 0 0 0 HI 0 0 0 0 0 0 IA 0 0 0 0 0 0 ID 1 1 0 3 1 0 IL 0 0 0 0 0 0 IN 0 0 0 0 0 0 KS 0 0 0 0 0 0 KY 1 0 0 3 0 0 LA 0 2 2 0 3 5 MA 1 2 0 1 2 0 MD 0 0 0 0 0 0 ME 0 0 0 0 0 0 MI 1 0 0 34 0 0 MN 1 0 0 6 0 0 MO 0 0 0 0 0 0 MS 0 0 0 0 0 0 MT 2 1 0 3 3 0 NC 0 0 0 0 0 0 ND 0 0 0 0 0 0 NE 2 0 0 8 0 0 State United States Page 35 January to June 2013 July to December 2014 January to June 2014 GAO-16-334 Sexual Assault Exam Readiness Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training Number of Arrest grantees that provided training for examiners Number of examiners who received training from Arrest grantees January to June 2013 July to December 2014 January to June 2014 NH 0 0 0 0 0 0 NJ 0 0 0 0 0 0 NM 0 0 0 0 0 0 NV 0 0 0 0 0 0 NY 1 2 0 17 14 0 OH 0 0 1 0 0 82 OK 1 1 1 1 6 16 OR 0 1 0 0 7 0 PA 0 0 0 0 0 0 RI 0 0 0 0 0 0 SC 1 0 0 1 0 0 SD 0 0 0 0 0 0 TN 0 0 0 0 0 0 TX 0 0 0 0 0 0 UT 1 1 1 205 329 199 VA 2 2 1 6 5 5 VT 0 0 0 0 0 0 WA 0 2 1 0 3 1 WI 1 1 0 15 17 0 WV 1 1 1 67 1 1 WY 0 0 0 0 0 0 State January to June 2013 July to December 2014 January to June 2014 Source: Department of Justice GAO-16-334 Page 36 GAO-16-334 Sexual Assault Exam Readiness Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training Table 7: Total Number of Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural) Grantees that Provided Training for Sexual Assault Forensic Examiners, and Total Number of Examiners Who Received Training by State, 2013 and 2014 Number of Rural grantees that provided training for examiners Number of examiners who received training from Rural grantees January to June 2013 July to December 2013 January to June 2014 January to June 2013 July to December 2013 January to June 2014 15 15 15 185 97 82 AK 0 0 0 0 0 0 AL 0 0 0 0 0 0 AR 0 0 0 0 0 0 AZ 0 0 0 0 0 0 CA 0 0 0 0 0 0 CO 2 2 1 14 5 5 CT 0 0 0 0 0 0 DC 0 0 0 0 0 0 DE 0 0 0 0 0 0 FL 0 0 0 0 0 0 GA 1 0 0 2 0 0 HI 0 0 0 0 0 0 IA 1 1 1 35 25 7 ID 0 0 0 0 0 0 IL 0 0 0 0 0 0 IN 0 0 0 0 0 0 KS 0 0 0 0 0 0 KY 0 0 0 0 0 0 LA 0 1 1 0 1 1 MA 0 0 0 0 0 0 MD 0 0 0 0 0 0 ME 0 1 1 0 1 24 MI 0 0 0 0 0 0 MN 0 0 0 0 0 0 MO 0 0 0 0 0 0 MS 0 0 0 0 0 0 MT 1 0 0 16 0 0 NC 1 1 1 9 4 6 ND 0 0 0 0 0 0 NE 1 2 1 1 2 1 NH 0 0 0 0 0 0 State United States Page 37 GAO-16-334 Sexual Assault Exam Readiness Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training Number of Rural grantees that provided training for examiners Number of examiners who received training from Rural grantees January to June 2013 July to December 2013 January to June 2014 January to June 2013 July to December 2013 January to June 2014 NJ 0 0 0 0 0 0 NM 1 1 0 16 1 0 NV 1 1 0 1 2 0 NY 0 0 0 0 0 0 OH 0 0 1 0 0 4 OK 0 1 1 0 31 14 OR 1 2 1 1 6 1 PA 0 0 0 0 0 0 RI 0 0 0 0 0 0 SC 0 0 1 0 0 1 SD 0 0 0 0 0 0 TN 1 1 1 48 16 6 TX 1 0 0 4 0 0 UT 2 0 2 10 0 2 VA 0 0 0 0 0 0 VT 0 0 0 0 0 0 WA 0 0 0 0 0 0 WI 0 0 0 0 0 0 WV 0 1 1 0 3 5 WY 1 0 1 28 0 5 State Source: Department of Justice GAO-16-334 Page 38 GAO-16-334 Sexual Assault Exam Readiness Appendix II: GAO Contact and Staff Acknowledgements Appendix II: GAO Contact and Staff Acknowledgements GAO Contact Katherine M. Iritani, (202) 512-7114 or iritanik@gao.gov Staff Acknowledgements In addition to the contact named above, Kristi Peterson (Assistant Director), Leia Dickerson, Katherine Mack, Laurie Pachter, and Emily Wilson made key contributions to this report. (291274) Page 39 GAO-16-334 Sexual Assault Exam Readiness GAO’s Mission The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO’s commitment to good government is reflected in its core values of accountability, integrity, and reliability. Obtaining Copies of GAO Reports and Testimony The fastest and easiest way to obtain copies of GAO documents at no cost is through GAO’s website (http://www.gao.gov). Each weekday afternoon, GAO posts on its website newly released reports, testimony, and correspondence. To have GAO e-mail you a list of newly posted products, go to http://www.gao.gov and select “E-mail Updates.” Order by Phone The price of each GAO publication reflects GAO’s actual cost of production and distribution and depends on the number of pages in the publication and whether the publication is printed in color or black and white. Pricing and ordering information is posted on GAO’s website, http://www.gao.gov/ordering.htm. Place orders by calling (202) 512-6000, toll free (866) 801-7077, or TDD (202) 512-2537. Orders may be paid for using American Express, Discover Card, MasterCard, Visa, check, or money order. Call for additional information. Connect with GAO Connect with GAO on Facebook, Flickr, Twitter, and YouTube. Subscribe to our RSS Feeds or E-mail Updates. Listen to our Podcasts and read The Watchblog. Visit GAO on the web at www.gao.gov. To Report Fraud, Waste, and Abuse in Federal Programs Contact: Website: http://www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov Automated answering system: (800) 424-5454 or (202) 512-7470 Congressional Relations Katherine Siggerud, Managing Director, siggerudk@gao.gov, (202) 5124400, U.S. Government Accountability Office, 441 G Street NW, Room 7125, Washington, DC 20548 Public Affairs Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149 Washington, DC 20548 Please Print on Recycled Paper.