anypatlent Identifying Information to them
it this kit to a ?Non-Report" to law enforcean fold and tape the form to the outside of the kit.

Hospital Mgmd?fg'f? #05th

DATA COLLECTION FORM
I. Examiner MUST com the data collection form and return to the STEP 1 envelope found In the kit.
Collection Form.

 

 

 

 

 

Date [a l6 4,20 County any 4a 
1. TIME FRAME
Time patient arrived (J Time patient discharged

Date of aswul?? Time of? assault 0 .2100 Time since assault 

County/State where patient resides

 

County/State where assault occurred 4? 0-2

2. PATIENT DATA A
Gender of patient IX Female Male Age of patient 
Gender of assailant Female Age of assailant (if known)

Assailanl's Relationship to Patient Relative BIKnown/Non-relalive Stranger
3. MEDICAL FORENSIC EXAMINATION

 

 

 

 

 

 

Exam performed? Yes No If no, why? Patient declined Examiner deferred
Patient left Other Please explain

Kit collected? Yes No If no. why? .

4. LAW ENFORCEMENT

Law enforcement notified? UYes No LE responded? D?Yes No

Kit released to law enforcement? Yes No Date released__

If no. is this a non-report? Yes No (Kits that are non-reports are shipped to Marshall University Forensic Science Center (MUFSC).

5. ADVOCACY

Advocate notified? Yes No Advocate responded? Yes No

Advocate services accepted by patient Yes No

if no, why? A

noti?ed? Yes :1 No responded? Was I: No

6. ASSAULT INFORMATION 

 

Type of assault: Attempted sexual assault? D?Yes No
If no, what prevented the sexual assault? 'pff??h ?it/c?/A @Jeoom 
4? (7m 2mm

 

 

 

 

 

 

 

 

 

 

 

Oral penetration? in Yes No
Vaginal penetration? Penile Digital Other
Anal penetration? Penile Digital Other
Condom used? Yes No Unsure
Weapons used? Yes ?No if Yes. Gun Knife Blunt Object
Any coercion used? Yes No If Yes, Verbal Threats Grabbing Stranguletion
Physical Blows Burns
Other:
Physical Injuries? Yes No Medical treatment received for injuries? Yes No
7. CONTRACEPTION (EC)
Prophylactic treatment offered? Yes No ifno. why?
Patient accepted prophylactic treatment Yes No
What kind of EC offered? Oral Plan Other
Was EC Administeredon site? Yes No If no: Prescription only? Yes No
Tested for STls? Yes No
Treated for Yes No
8. DRUG FACILITATED SEXUAL ASSAULT
Suspected drug facilitated sexual assault ,9 Yes No
If yes. what drug is suspected? MM if!? ?if
Loss of memory? Yes a No Unsure Lapse of consciousness? Yes No Unsure
If yes. describe
Examiner is a: Sane Physician Assistant Advanced Practice Nurse Other
If a SANE: Adult/Adolescent Trained Pediatric Trained of years of experience as a SANE
Revised?iis
1FTURN COMPLETED DATA FORM TO KIT. 6?15

3