11-Attachment H- Sexual Assault Examination Form.pdf

STATE OF UTAH SEXUAL ASSAULT EXAMINATION

Page 1 of 11 Patient Label Updated 12/17/2025

Report of History and Findings

CASE INFORMATION

Date of Exam (mm/dd/yyyy) Time Exam Started LE Case No Exam Location Agency Case Number (SANE, Hospital, CJC, etc.)

Law Enforcement (LE) Agency

Assisting Agency Assisting LE Case No SAK Number UBFS RESTRICTED KIT c Yes c No (Must be18 years of age or older )

PATIENT DEMOGRAPHICS

DOB (mm/dd/yyyy) Age

Sex Assigned at Birth c Male c Female c Intersex Language_____________

Gender Identity c Male c Female c Transgender M to F Female c Transgender F to M Male cOther

Pronouns: Chosen Name:

Race c White c Black c LatinX c Asian c Pacific Islander c American Native c Other

Does the patient have a guardian who must legally consent for the examination? c Yes c No

Patient Complaint Chief Complaint Sexual Assault Pain Score (1/10):

Patient complaining of pain or injury c Yes c No If yes, describe the location/ source & intervention:

Medical History

VITAL SIGNS

Height

Weight

Temp

B/P

Pulse

Resp

O2 Sat

Per ED c

Current Medication(s) c Yes c No If yes

Contraception Use: Yes N/A Allergies to Medication c Yes c No

If yes

Current Medical Problems c Yes c No If yes

Surgeries/Medical Procedures c Yes c No If yes

Tetanus c Current c 10+ yr c Unk

Hepatitis B Vaccine c Yes c No c Unk

HPV Vaccine c Yes c No c Unk

LMP c NA

Age of Menarche c NA

Prior Vaginal deliveries c Yes c No c NA

Consensual sex in last 6 days c Yes c No If yes, type of contact

Date of contact

Name of Partner

Gender of Partner

Page 2 of 11 Patient Label Updated 12/17/2025

History of Sexual Assault Date and Time of Assault

Location c House/Apartment c Car c Outside c Hotel c Other

Surface Assault Occurred on

Summary of Assault Described by Patient

Patient’s Actions The following questions are to guide the medical exam and identify sources of evidence

Patient’s Actions Yes No Unk Description

Scratch c c c

Bite c c c

Pushed or Hit c c c

Kick c c c

Other c c c

Page 3 of 11 Patient Label Updated 12/17/2025

Suspect #_____ Name of Suspect(s) (Description if Unknown)

Relationship to Suspect c Acquaintance c Spouse/Partner c Ex-partner c Stranger c Other

Describe Suspect’s Dress During Assault

Describe Patient’s Dress During Assault

Suspect’s Actions Yes No Unk Description

Verbal threats/coercion c c c

Grabbed/held c c c

Physical blows c c c

Strangled (Choked) c c c See strangulation documentation

Weapon c c c

Restraints c c c

Other c c c

Nature of Sexual Assault

PATIENT

Was there contact with patient’s GENITALIA by?

Yes No Unk Penis/Genitals c c c

Finger/Hand c c c Describe Object/Other c c c Object

Was there contact with patient’s ANUS by?

Yes No Unk

Penis/Genitals c c c Finger/Hand c c c Describe Object/Other c c c Object

Was there contact with patient’s MOUTH by?

Yes No Unk

Penis/Genitals c c c Finger/Hand c c c Describe Object/Other c c c Object

SUSPECT

Ejaculation c Yes c No c Unk

If yes, where

Condom c Yes c No c Unk

SUSPECT CONT

Lubrication c Yes c No c Unk

If yes, type

Suspect Washed/Cleaned Patient c Yes c No c Attempted c Unk If yes, describe

Did suspect’s MOUTH contact patient’s?

Yes No Unk

Genitals c c c Breasts c c c Mouth c c c

Anus c c c Describe Neck c c c Other

Did suspect’s HANDS or BODY hold or rub against patient’s?

Yes No Unk Neck c c c

Breasts c c c Extremity c c c Describe

Other c c c Other

(If more than one suspect, complete additional copies of this page for each additional suspect)

Suffocation/ Head or Face Trauma

Other c c c

Page 4 of 11 Patient Label Updated 12/17/2025

Indicators of Drug Facilitated Sexual Assault Patient provided with food, drink, drugs prior to assault by suspect(s)? c Yes c No If yes

Patient used drugs/alcohol before assault? c Yes c No If yes

Suspect used alcohol/drugs near time of assault? c Yes c No c Unk If yes

Patient lost consciousness/awareness? c Yes c No If yes

Post Assault Actions by Patient (Check all that apply)

Yes No Unk Description Yes No Unk Description Urinated c c c Ate/Drank c c c

Defecated c c c Bathed/Showered c c c

Vomited c c c Genital Wipe/Wash c c c

Brushed Teeth c c c

Removed/Inserted c c c

Gargled/Rinsed Tampon/Pad/Diaphragm

General Physical Exam

Describe general demeanor/appearance:

Did patient appear to have any cognitive or developmental disability? c Yes c No If yes

Page 5 of 11 Patient Label Updated 12/17/2025

Check if no trauma

If not normal, describe abnormal/trauma findings (Use body diagrams to document findings)

Patient Statement: When and How Injury Occurred

Neuro c

Head/Face c

Eyes c

Ears c

Oral c

Neck c

Chest/ Breasts c

Back/Buttocks c

Abdomen

Extremities

Other c c c

PERRLA

GCS

Y / N

Y / N number_____

Page 6 of 11 Patient Label Updated 12/17/2025

Check if No Trauma

Check if No Trauma

Check if No Trauma

Page 7 of 11 Patient Label Updated 12/17/2025

Right Side Left Side

Check if No Trauma

Check if No Trauma

Page 8 of 11 Patient Label Updated 12/17/2025

FEMALE ADOLESCENT / ADULT ANOGENITAL EXAM

c Diagram sheet not applicable c Not examined due to ___________________________________ Check if no trauma

If not normal, describe abnormal/trauma findings (Use these body diagrams to document findings)

Inner Thighs c

Clitoral Hood

/ Clitoris c

Labia Majora c

Labia Minora c

Periurethral Tissue and Urethra c

Perihymenal Tissue c

Hymen c

Vagina/ Cervix c

Fossa Navicularis c

Posterior Fourchette c

Perineum c

Anus/Rectum c

Other c speculum used? Y / N not examinedc

Page 9 of 11 Patient Label Updated 12/17/2025

MALE ANOGENITAL EXAM

c Diagram sheet not applicable c Not examined due to __________________________________

Check if no trauma

If not normal, describe abnormal/trauma findings (Use these body diagrams to document findings)

Inner Thighs c

Perineum c

Glans Penis c

Penile Shaft c

Urethral Meatus c

Scrotum c

Testes c

Perianal c

Anus c

Rectum c

Penile

Discharge

Y__N__

Page 10 of 11 Patient Label Updated 12/17/2025

FEMALE CHILD/EARLY ADOLESCENT ANOGENITAL EXAM

c Diagram sheet not applicable c Not examined due to __________________________________ Check if no trauma

If not normal, describe abnormal/trauma findings (Use these body diagrams to document findings)

Inner Thighs c

Vulva c

Clitoral Hood/ Clitoris c

Labia Major c

Labia Minor c

Periurethral Tissue and Urethra c

Perihymenal Tissue c

Hymen c

Vagina c

Fossa Navicularis c

Posterior Fourchette c

Perineum c

Anus/ Rectum c

Page 11 of 11 Patient Label Updated 12/17/2025

Must have victim standard to process kit.

Buccal standard c Yes c No

Consensual Partner (name) Buccal standard c Yes c No

Yes No

Blood-Grey Top (tox) c c Time

Urine (tox) c c Time

Hands Swabbing c c

Fingernail swabbing c c

Debris c Yes c No If yes

Patient’s clothing collected c Yes c No If yes

Other specimens c Yes c No If yes

Anal/genital photo-documentation c Yes c No

Other photo-documentation c Yes c No

Toluidine Blue 1% Dye used c Yes c No

SWABS

Yes No

Oral contact c c

Pubis to anus c c

Vaginal Vault c c

Internal Anal c c

Penile/Scrotum c c

Other ________ c c Skin swab c Yes c No

Location

Skin swab c Yes c No Location

Skin swab c Yes c No Location

Skin swab c Yes c No Location

Skin swab c Yes c No Location

Skin swab c Yes c No Location

Pregnancy test c N/A c Blood c Urine Result c Positive c Negative

Medications c Given by ED/Clinic c Given by Forensic Nurse Antibiotics c None c Ceftriaxone (Rocephin) 500 mg IM c Metronidazole 500mg PO BID #14 c Doxycycline 100 mg BID # 14 or c Azithromycin 1gm PO c Other ______________ Emergency contraception c Levonorgestrel 1.5 mg PO or c Ulipristal 30mg c None Other medications provided by ED/Clinic c None c Zofran c HIV nPEP c Immunization(s) ________________

Reporting and Referral Information

Patient given discharge instructions c Yes c No APS notified c Yes c No Case # _____________ DCFS notified c Yes c No Case# ____________ Provider consultation

Printed name of examiner(s)

Signature of examiner(s)

Time exam complete

Laboratory / Forensic Specimens Collected

* Patient indicates contact in area of swab:

A=Amylase, S=Seminal fluid, E=Epithelial

Evidence Notes: