Attachment 2d - Patient Consent Form.pdf

Illinois State Police

Original to law enforcement case file, copy to hospital medical record, copy to patient.

DO NOT SEAL THIS PAGE IN THE EVIDENCE COLLECTION KIT

ISP 6-003 (1/23)

Division of Forensic Service Patient Consent: Collect and Test Evidence or Collect and Hold Evidence

Medical Forensic Exam: Patient of any age. If patient is unable to provide consent due to age or mental status, consent may be obtained from parent or guardian.

Initial one choice I consent to I decline a medical forensic exam. I understand I can stop the exam at any time and can decline any portion of the exam. I understand that I will not be charged for any outpatient portion of the medical forensic exam. If declined, I understand that I can return to any facility for medical attention.

___ I am choosing to provide information directly to a law enforcement officer. I understand that I may decide how much information I provide and that I may stop the interview at any time. I consent only to the collection and storage of evidence at a law enforcement agency. I understand this means the evidence will NOT be submitted to a forensic lab for analysis. I understand I can change my mind, release the evidence and possibly have evidence analyzed at a forensic lab by contacting law enforcement or a rape crisis center at a later time. I understand law enforcement is only required to hold the evidence for a minimum of 10 years or until the 28th birthday of a patient under the age of 18.

___ I am choosing to allow health care providers to provide information to law enforcement regarding the sexual assault. I acknowledge that I do not have to speak with law enforcement at this time. I consent only to the collection and storage of evidence at a law enforcement agency. I understand this means the evidence will NOT be submitted to a forensic lab for analysis. I understand I can change my mind, release the evidence and possibly have evidence analyzed at a forensic lab by contacting law enforcement or a rape crisis center at a later time. I understand law enforcement is only required to hold the evidence for a minimum of 10 years or until the 28th birthday of a patient under the age of 18. I will call law enforcement

Law enforcement can call me after _____day(s)

Sign here if patient or health care provider report selected

Initial here if non-report and hold selected

Photographic Evidence: (must be 13 years old or older. If under 13 years old, consent may be obtained from parent or guardian, please circle) Initial one choice _____I consent to _____I decline the collection of photographic evidence. I understand these photos may include injuries and photos of my genital area. I understand law enforcement may request photos independent of the medical forensic exam if I choose to make a report.

___ I am choosing to provide information directly to a law enforcement officer. I understand that I may decide how much information I provide and that I may stop the interview at any time. I give permission for evidence and information gathered during my medical forensic exam to be released to law enforcement and analyzed at the forensic lab. I understand law enforcement will submit the evidence to a lab no later than 10 days after receiving it. I understand if the evidence is analyzed, law enforcement will receive the results for the purposes of investigation(s) and prosecution(s).

___ I am choosing to allow health care providers to provide information to law enforcement regarding the sexual assault. I acknowledge that I do not have to speak with law enforcement at this time. I give permission for evidence and information gathered during my sexual assault exam to be released to law enforcement and analyzed at the forensic lab. I understand law enforcement will submit the evidence to a lab no later than 10 days after receiving it. I understand if the evidence is analyzed, law enforcement will receive the results for the purposes of investigation(s) and prosecution(s). I will call law enforcement

Law enforcement can call me after _____day(s)

DOB ____________ Hospital Medical Record No. ____________________________

Patient Report & Hold: Option A Hold

Patient Report & Test: Option A Test

Health Care Provider Report & Test:

Option B Test

Health Care Provider Report & Hold:

Option B Hold

Reporting Decision and Evidence Analysis: Initial one choice only from the 5 options below.

(must be 13 years old or older. If under 13 years old, consent may be obtained from parent, guardian, law enforcement or DCFS)

Patient Label

DO NOT COMPLETE THIS BOX WITHOUT CONSENT.

Evidence Collection: Patient of any age. If patient is unable to provide consent due to age or mental status, consent may be obtained from parent or guardian.

Initial one choice I consent to I decline evidence collection. I understand I can stop the exam at any time and can decline collection of any sample. I understand that I will not be charged for any outpatient portion of the medical forensic exam. If declined, I understand that I can return to any treatment facility within 7 days of the assault and request that and evidence collection be completed

Non-Report & Hold:

Option C Hold

___ At this time I am choosing NOT TO REPORT TO LAW ENFORCEMENT OR PARTICIPATE in any investigation. I consent only to the collection and storage of evidence at a law enforcement agency. I understand this means the evidence will NOT be submitted to a forensic lab for analysis. I understand I can change my mind, make a report to law enforcement and possibly have evidence analyzed at a forensic lab by contacting law enforcement or a rape crisis center at a later time. I under- stand law enforcement is only required to hold the evidence for a minimum of 10 years or until the 28th birthday of a patient under the age of 18. (See page 2 mandated reporter clause)

Illinois State Police

Original to law enforcement case file, copy to hospital medical record, copy to patient.

DO NOT SEAL THIS PAGE IN THE EVIDENCE COLLECTION KIT ISP 6-003 (1/23)

Return to Consent for Evidence Analysis (To be completed at a later time if evidence and information gathered during my medical forensic exam to be released to law enforcement and analyzed at the forensic lab. I understand law enforcement will submit the evidence to a lab no later 10 days from today. I understand if the evidence is analyzed, law enforcement will receive the results for the purpose of investigation(s) and Prosecution(s).

Division of Forensic Services

Patient Consent: Collect and Test Evidence or Collect and Hold Evidence, Page 2 Contact Information

Receipt of Information (to be completed by hospital and law enforcement representatives only)

______________________________ HOSPITAL STOP HERE _______________________________

I certify that I have received the following items (check those that apply):

______ One sealed evidence collection kit K#__________________ ______Copy of the medical forensic documentation ______ Sealed paper clothing bag(s) (if more than one, please note) ______Sealed urine specimen ______ Pre-void external genital wipe ______Other (describe) _____________________________

Evidence Transfer Date_____________ Time________

Signature of law enforcement representative receiving information and/or articles__________________________________________

Printed Officer ID# and Rank _________________________________ Agency ___________________________________

Signature of hospital representative releasing information and/or articles_________________________________________________

Printed hospital reprehensive name and title_______________________________________________________________________

Untested storage period ends ________ (10 years after date of exam or the 28th birthday for a patient under 18. If patient consented to testing, mark N/A)

I have provided law enforcement with information regarding the sexual assault. I give permission for evidence and information gathered during my medical forensic exam to be released to law enforcement and analyzed at the forensic lab. I understand law enforcement will submit the evidence to a lab no later than 10 days from today. I understand if the evidence is analyzed, law enforcement will receive the results for the purposes of investigation(s) and prosecutions(s)

Patient Signature Witness Signature

Law Enforcement Representative

Medical Forensic Documentation I consent to having my medical forensic documentation forms provided to law enforcement. PATIENT TO INITIAL HERE________

Date

Date

Patient Label

DO NOT COMPLETE THIS BOX WITHOUT CONSENT.

If you have consented for testing you can receive information about the status of testing and results of your evidence collection kit by contacting the law enforcement agency listed below:

Law Enforcement Agency Report #

Address Phone Number

Rape Crisis Center Phone Number

Mandated Reporter Clause I understand that pursuant to 20 ILCS 2630/3.2 it is the duty of any physician or nurse to notify the local law enforcement agency of that jurisdiction when it reasonably appears that the person requesting treatment has received any injury sustained in the commission of or as a victim of a criminal offense. PATIENT TO INITIAL HERE _________