sexual assault examination record - vifm assault examination record confidential this document is...

Document ID: FR-12-0034-1.0 of 19

Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014

Victorian Institute of Forensic Medicine

Sexual Assault Examination Record

Confidential

This document is intended as a guide to the forensic medical examination and should be used at the examiner’s discretion.

Forensic Medical Examination Record (Sexual Assault)

Name:…………………………………………………......DOB:………………



CLINICAL FORENSIC MEDICAL EXAMINATION

EXAMINERS NAME:

Forensic Medical Officer

Forensic Registrar

Forensic Nurse Examiner

Other:

………………………………………………………

Place FMEK Label Here

Date of examination:

Time Case Commenced:

Time Case Concluded:

PATIENT DETAILS

Name:

Date of birth:

Gender: M F

Contact Phone Number:

EXAMINATION DETAILS

Location

Monash Medical Centre

Royal Women’s Hospital

Maroondah

Austin Hospital

Sunshine

Frankston

Regional CCU (Specify):

…………………………………………………………

Other:

…………………………………………………………

INFORMANT DETAILS

Rank & Name

DX:

Station/SOCIT:

……………………………………..………….

Phone:

……………………………………………..….

OBSERVER DETAILS

1. Name:……………………………………….

Role:………………………………………….

Stages Present:

History Examination Both

2. Name:…………………………………………........

Role:………………………………………………….

Stages Present:

History Examination Both


Name:…………………………………………………......DOB:………………



CONSENT FOR MEDICO-LEGAL CONSULTATION1

The Forensic Examiner in this case has explained to me the procedures of examination,

evidence collection and release of findings to Police and/or in Courts.

I …………………………………………………………..(Insert patient’s name), agree to the following:

(Mark each as appropriate)

Medical Examination (including

examination of the genitalia and

anus)

Providing a verbal and/or written report

to Police.

Collection of specimens for medical

investigations Collection of specimens for forensic

investigations

Photography Non-identifying data can be used for

quality assurance, teaching and

research activities.

A phone call from the Forensic Examiner for follow-up purposes. Best time of day to call:

….…… : ……….. am/pm

- AND –

Authorise the Forensic Examiner to release the collected forensic specimens to Police.

Patient/Guardian Signature Date: ……./…..…. /………

Examiner’s Signature Date: ……./…..…. /………

Patient unable to provide consent.

Forensic Medical Examination

deferred.

Details:

Patient unable to provide consent.

Consent obtained from:

.…………………………………………………...

Details:

Patient declined Forensic Examination on this occasion.

Details:

1 The person must be provided with a detailed explanation of what is proposed during the consultation so they

are able to give informed consent. This should include the examination procedures (particularly details of any

proposed examination of the genitalia or anus), photography, specimen collection, any treatment, and the

release of information to other parties. This should be provided in a language that is readily understood by the

patient.


Name:…………………………………………………......DOB:………………



CASE DETAILS

SUMMARY FROM POLICE (or others)

Details provided by (name):

RELEVANT PAST MEDICAL HISTORY

GYNAECOLOGICAL HISTORY

Last menstrual period? …………………………

Was patient menstruating at the time of the assault? Yes No Unsure/Not asked

Is the patient pregnant? Yes No Unsure/Not asked

Contraception? (Type?) …………………… ..…………. Yes No Unsure/Not asked

History of genital trauma/pathology/surgery Yes No Unsure/Not asked

…………………………………………………………………………………………………………………………………

OTHER RELEVANT MEDICAL/SURGICAL/PSYCHIATRIC HISTORY

MEDICATIONS/IMMUNISATIONS

Hepatitis B Tetanus

Allergies:

.................................................................................

.................................................................................

Medications(Specify):

…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

CONSUMED DRUGS and/or ALCOHOL (Type, amount, timing)

Alcohol

Drugs

(Specify):

....................................................................................................................................................................

....................................................................................................................................................................

....................................................................................................................................................................

....................................................................................................................................................................


Name:…………………………………………………......DOB:………………



HISTORY OF ASSAULT

Location:

DATE

TIME

Own Home Other’s Home

…… /……. /……

….. : …. am/pm Car Outdoors

Venue e.g.

(Nightclub)

Other (Specify):

……………………………………………………………………………

……………………………………………………………………………

…………………

……………..…..

Details from the patient (or if other specify who):


Name:…………………………………………………......DOB:………………



Extra Notes ………………………………………………………………………………………………………………………

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Name:…………………………………………………......DOB:………………



ANOGENITAL CONTACT SUMMARY

History of Vaginal Contact or Penetration Yes No Unsure/Not asked

Vaginal Pain Yes No Unsure/Not asked

Vaginal Bleeding Yes No Unsure/Not asked

Urinary Symptoms Yes No Unsure/Not asked

Vaginal Symptoms

Yes No Unsure/Not asked

Summary Description:

History of Anal Contact or Penetration


Anal Pain Yes No Unsure/Not asked

Anal Bleeding Yes No Unsure/Not asked

Bowel Symptoms Yes No Unsure/Not asked


(Include details of pre and post assault bowel actions)

History of Oral Contact or Penetration Yes No Unsure/Not asked

Oral Symptoms



EJACULATION:

Vagina Yes No Unsure

Other body site Yes No Unsure (please specify):

Anal Yes No Unsure

Oral Yes No Unsure

Condom used Yes No Unsure Lubricant used Yes No Unsure


Name:…………………………………………………......DOB:………………



POST-ASSAULT

Pre-assault Intercourse within previous week Yes No Not asked

Time: :

Who:

Date: ………/……… /………

Post-assault Intercourse Yes No Not asked

Time: :

Who:

Date: ………/……… /………

OTHER

History of Bite/s Yes No

Not asked/Not answered

Site(s):

Other Trauma (Specify):

History of trauma to Neck

Loss of consciousness

Breathing difficulties

Pain on swallowing

Sore throat

Hoarse voice

Referral to Emergency

Department

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No Unsure

Yes No

CURRENT SYMPTOMS

POST-ASSAULT DETAILS

Brushed Teeth Yes No N/A

Rinsed Mouth Yes No N/A

Tampon/Pad Used Yes No N/A

Bathed/Showered Yes No N/A

Changed Clothes Yes No N/A

Cleaned Clothes Yes No N/A

Clothes given to police Yes No N/A

EXAMINATION

APPEARANCE: (Place findings here. Use body charts for diagrams. Indicate any sites not examined)

Signs of Alcohol/drug effect

Behaviour

Cognitive functioning


Name:…………………………………………………......DOB:………………



Not Examined Nil Injury Noted

Right Left

Right Left


Name:…………………………………………………......DOB:………………





Name:…………………………………………………......DOB:………………




Right Left


Name:…………………………………………………......DOB:………………




Left Right


Name:…………………………………………………......DOB:………………




Right

Inner Outer

Left

Outer Inner


Name:…………………………………………………......DOB:………………



Speculum Examination Conducted Yes No

Proctoscopy Conducted Yes No



Name:…………………………………………………......DOB:………………



PHOTOGRAPHS

Taken By :

Self Other (Specify) Not Taken

TOXICOLOGY

Toxicology samples taken: Yes (Complete Toxicology Form) No

MEDICATION PROVIDED

(Ensure script written and hospital record completed)

Emergency contraception Yes No

Azithromycin Yes No

Hep B immunoglobulin/immunisation Yes No

NPEP Yes No

Other (specify):

HOSPITAL PATHOLOGY COLLECTED

Please specify:

REFERRAL

GP

Emergency Department

Letter written

Psychiatric Services

Sexual Assault Follow-up Clinic

Other: ……………………………………………………

Referral Contact:

Treatment and Advice:

LIMITATIONS TO EXAMINATION OR OPINION

Patient Location Equipment

Details:


Name:…………………………………………………......DOB:………………



Proctoscopy Conducted Yes No



Name:…………………………………………………......DOB:………………



This page is left blank intentionally.


Name:…………………………………………………......DOB:………………



FORENSIC SAMPLES Date of assault: …………………….……….

Time of assault:……………………………..

Examiner:……………………….……..……

Date of examination:……………….…………

Time:……………..…………….……………..

FMEK #:……………………………………..

DATA AVAILABLE

Number of offenders:………………

Known Acquaintance

Unknown Other: …………………

Vaginal penetration

Finger Penis

Ejaculation Other: …………

Anal Penetration

Finger Penis

Ejaculation Other: …………………

Oral Penetration

Penis Ejaculation

Other site of ejaculation

……………………………………………..…..

…………………………………………………

Condom

Lubricant

Saliva suspected (kissed, licked or bitten?)

Site:…………………………………………….

…………………………………………………

…………………………………………………

Forensic Dentist consulted

Showered / washed

Suspected Drug Facilitated Sexual Assault

Specific details regarding clothing? (ie washed post

assault, location of marks/stains etc)

…………………………………………….……

………………………………….………………

Sexual Contact prior to the assault: (<7 days)

………..……………………………………………

………………………………………….

……………………………………………….

COMPARISON SAMPLES

2 x Buccal swabs/blood for DNA:…................. (PLEASE KEEP REFERENCE SWAB SEPARATE FROM OTHER SAMPLES WHEN HANDING OVER TO POLICE (ie put in separate

labelled envelope)

Hair: Head/Pubic:…………….......................

SAMPLES

Underpants: ...........................................

Clothing ( bags) contents: ...........................................

...........................................

Drop sheet: ...........................................

Tampon/Pad: ...........................................

Condom: ...........................................

Other: ...........................................

...........................................

BODY EVIDENCE Oral swab and slide: ...........................................

Mouth rinsings (20 ml in a

sterile container): ...........................................

Foreign material on body Site: ...........................................

Skin swab(s) / slide for

semen/saliva [wet / dry] Site: ...........................................


semen/saliva [wet / dry] Site: ......................../..................



Fingernail scrapings -

RIGHT/LEFT: ......................./...................

Hair Samples: ...........................................

ANO-GENITAL EVIDENCE

Foreign material: ...........................................

Vulval swab(s) and slide(s)

Number: ...........................................

High vaginal swab(s) and

slide(s) Number: ...........................................

Endocervical swab(s) and

slide(s) Number: ...........................................

Penile shaft swab(s) and

slide(s) Number: ......................../..................

Penile glans swab(s) and

slide(s) Number: ......................../..................

Anal swab(s) and slide (s)

Number: ......................./...................

Other (specify): ...........................................

DRUG SCREENING - complete separate form

Blood for alcohol and drugs

(VIFM kit/other): ...........................................

Urine for drugs: ...........................................

OTHER DETAILS OF RELEVANCE:…………………………………………………………………………….

…………………………………………………………………………………………………….

HANDED TO:

TIME & DATE:

Signed:


Name:…………………………………………………......DOB:………………

Document ID: FR-12-0034-1.0 Page 17 of 19


FORENSIC SAMPLES Date of assault: …………………….……….

Time of assault:……………………………..

Examiner:……………………….……..……

Date of examination:……………….…………

Time:……………..…………….……………..

FMEK #:……………………………………..

DATA AVAILABLE

Number of offenders:………………

Known Acquaintance

Unknown Other: …………………

Vaginal penetration

Finger Penis

Ejaculation Other: …………

Anal Penetration

Finger Penis

Ejaculation Other: …………………

Oral Penetration

Penis Ejaculation

Other site of ejaculation

……………………………………………..…..

…………………………………………………

Condom

Lubricant

Saliva suspected (kissed, licked or bitten?)

Site:…………………………………………….

…………………………………………………

…………………………………………………

Forensic Dentist consulted

Showered / washed

Suspected Drug Facilitated Sexual Assault

Specific details regarding clothing? (ie washed post

assault, location of marks/stains etc)

…………………………………………….……

………………………………….………………

Sexual Contact prior to the assault: (<7 days)

………..……………………………………………

………………………………………….

……………………………………………….

COMPARISON SAMPLES

2 x Buccal swabs/blood for DNA:…................. (PLEASE KEEP REFERENCE SWAB SEPARATE FROM OTHER SAMPLES WHEN HANDING OVER TO POLICE (ie put in separate

labelled envelope)

Hair: Head/Pubic:…………….......................

SAMPLES

Underpants: ...........................................

Clothing ( bags) contents: ...........................................

...........................................

Drop sheet: ...........................................

Tampon/Pad: ...........................................

Condom: ...........................................

Other: ...........................................

...........................................

BODY EVIDENCE Oral swab and slide: ...........................................

Mouth rinsings (20 ml in a

sterile container): ...........................................

Foreign material on body Site: ...........................................


semen/saliva [wet / dry] Site: ...........................................





Fingernail scrapings -

RIGHT/LEFT: ......................./...................

Hair Samples: ...........................................

ANO-GENITAL EVIDENCE

Foreign material: ...........................................

Vulval swab(s) and slide(s)

Number: ...........................................

High vaginal swab(s) and

slide(s) Number: ...........................................

Endocervical swab(s) and

slide(s) Number: ...........................................

Penile shaft swab(s) and

slide(s) Number: ......................../..................

Penile glans swab(s) and

slide(s) Number: ......................../..................

Anal swab(s) and slide (s)

Number: ......................./...................

Other (specify): ...........................................

DRUG SCREENING - complete separate form

Blood for alcohol and drugs

(VIFM kit/other): ...........................................

Urine for drugs: ...........................................

OTHER DETAILS OF RELEVANCE:…………………………………………………………………………….

…………………………………………………………………………………………………….

HANDED TO:

TIME & DATE:

Signed:

FMEK COPY



…../…../……….

Dear Doctor,

RE: ___________________________________________________

Thank you for the ongoing care of this patient who was allegedly sexually assaulted ___days

ago. She/he underwent a forensic medical examination on ……../……/……...

Emergency contraception (POSTINOR-2) was given Yes No

Hepatitis B Immunoglobulin/Vaccination was given Yes No

There are injuries requiring follow-up Yes No

Further comments (including other medications given) -

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

She/he may require an STI screen in approximately 2 weeks. If urine/blood toxicology was

taken we will notify your patient of the result.

If a sexually transmitted infection or a pregnancy may have resulted from this sexual assault

would you kindly send me a copy of the results with your patient's permission?

Yours sincerely,

………………………………………………………..

Victorian Institute of Forensic Medicine Ph: (03) 9684 4480

Fx: (03) 9684 4481

PATIENT COPY



…../…../……….

Dear Doctor,

RE: ___________________________________________________

Thank you for the ongoing care of this patient who was allegedly sexually assaulted ___days

ago. She/he underwent a forensic medical examination on ……../……/……...

Emergency contraception (POSTINOR-2) was given Yes No

Hepatitis B Immunoglobulin/Vaccination was given Yes No

There are injuries requiring follow-up Yes No

Further comments (including other medications given) -

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

She/he may require an STI screen in approximately 2 weeks. If urine/blood toxicology was

taken we will notify your patient of the result.

If a sexually transmitted infection or a pregnancy may have resulted from this sexual assault

would you kindly send me a copy of the results with your patient's permission?

Yours sincerely,

………………………………………………………..

Victorian Institute of Forensic Medicine Ph: (03) 9684 4480

Fx: (03) 9684 4481



REQUEST FOR TOXICOLOGY (This form should be sent with the samples to VIFM via the attending police officer)

PATIENT NAME:…………………………DOB:…/……/……CONTACT PHONE NO. …...…….

CLINICIAN NAME: (Please Print) ……………………………………………………………………

□ Clinical Forensic Medicine □ VFPMS

□ Other. (Address) ………………………… ……………………………………………………….

………………………………………………………………. PH:…….……………………...

SAMPLE(S) COLLECTED (Blood & urine if < 24hrs OR Urine only if > 24 hrs since exposure to drug)

□ URINE (25mls in sterile container) Collection date / / Time: ……………hrs

□ BLOOD (10ml in fluoride/oxalate tube) Collection date / / Time: ……...…….hrs

REASON FOR COLLECTION (Tick those applicable – may be multiple)

□ Suspected drug administration by covert means (eg ‘drink spiking’)

□ Known drug administration /consumption

□ Suspected sexual assault whilst under influence of drugs/alcohol

□ Other (Specify) ………………………………………………………………………………………..

SUSPECTED DRUG (S)

Is a specific drug(s) suspected/sought? □ No □ Yes

Name/s: ……………………………………………………........................................................................

Specific symptoms/ signs indicating drug effect? (Observed or Account Provided)

……………………………..………………………………………………………..……………………..

……………………………………………………………………………………………………………..

………………………………………………………………………………………………..……………

KNOWN DRUG CONSUMPTION (In last two weeks including Prescription, OTC, Party, Illicit etc)

DRUG/MEDICATION

NAME

AMOUNT/DOSE LAST DOSE-

DATE/TIME

Has the patient used cannabis in the last 2 weeks? □ Yes □ No □ Unknown / Undetermined

KNOWN ALCOHOL CONSUMPTION (In last 24 hours)

TYPE / NAME AMOUNT DOSE DATE / TIME

Time of last alcoholic drink: …………………………………. ……………………………………

□ NIL ALCOHOL CONSUMED □ UNKNOWN IF ALCOHOL CONSUMED

CONFIDENTIAL

PATIENT NOTIFIED: REPORT SENT TO POLICE:

BY: BY:

DATE: DATE:

Further information: …………………………………………………………………………..…………..

…………………………………………………………………………………………………….................

……………………………………………………………………………………………………...

S…………



REQUEST FOR TOXICOLOGY (This form should be sent with the samples to VIFM via the attending police officer)

PATIENT NAME:…………………………DOB:…/……/……CONTACT PHONE NO. …...…….

DOCTOR’S NAME: (Please Print) ……………………………………………………………………

□ Clinical Forensic Medicine □ VFPMS

□ Other. (Address) ………………………… ……………………………………………………….

………………………………………………………………. PH:…….……………………...

SAMPLE(S) COLLECTED (Blood & urine if < 24hrs OR Urine only if > 24 hrs since exposure to drug)

□ URINE (25mls in sterile container) Collection date / / Time: ……………hrs

□ BLOOD (10ml in fluoride/oxalate tube) Collection date / / Time: ……...…….hrs

REASON FOR COLLECTION (Tick those applicable – may be multiple)

□ Suspected drug administration by covert means (eg ‘drink spiking’)

□ Known drug administration /consumption

□ Suspected sexual assault whilst under influence of drugs/alcohol

□ Other (Specify) ………………………………………………………………………………………..

SUSPECTED DRUG (S)

Is a specific drug(s) suspected/sought? □ No □ Yes

Name/s: ……………………………………………………........................................................................

Specific symptoms/ signs indicating drug effect? (Observed or Account Provided)

……………………………..………………………………………………………..……………………..

……………………………………………………………………………………………………………..

………………………………………………………………………………………………..……………

KNOWN DRUG CONSUMPTION (In last two weeks including Prescription, OTC, Party, Illicit etc)

DRUG/MEDICATION

NAME

AMOUNT/DOSE LAST DOSE-

DATE/TIME

Has the patient used cannabis in the last 2 weeks? □ Yes □ No □ Unknown / Undetermined

KNOWN ALCOHOL CONSUMPTION (In last 24 hours)

TYPE / NAME AMOUNT DOSE DATE / TIME

Time of last alcoholic drink: …………………………………. ……………………………………

□ NIL ALCOHOL CONSUMED □ UNKNOWN IF ALCOHOL CONSUMED

CONFIDENTIAL

PATIENT NOTIFIED: REPORT SENT TO POLICE:

BY: BY:

DATE: DATE:

Further information: …………………………………………………………………………..…………..

…………………………………………………………………………………………………….................

……………………………………………………………………………………………………...

S…………

POLICE COPY

sexual assault examination record - vifm assault examination record confidential this document is...

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