Sexual Assault Assessment With Consent/refusal Form And Evidentiary Log printable pdf download

Sexual Assault Assessment With Consent/refusal Form And Evidentiary Log

Sample Form For Consent/Refusal and Evidentiary Log

*Adapted from a form developed by St. Luke’s-Roosevelt Hospital Center

Date:_______________

Time of Exam:_______________AM/PM

Patient Name:_________________________________________ Contact No.:__________________________

SAFE *

1)_______________________________________ Contact No.:__________________________

Examiner(s)

2)_______________________________________ Contact No.:__________________________

Provider: ______________________________ Dept.:__________ Contact No.:__________________________

(If not a SAFE* Examiner)

*Sexual Assault Forensic Examiner

Patient Consent/Refusal

I understand that if I consent, an examination for evidence of sexual assault and collection of possible evidence

will be conducted. I understand that I may refuse to consent, or I may withdraw consent at any time for any

portion of the examination. I understand that the collection of evidence may include photographing injuries, which

may include injuries to the genital area. I understand that if I consent, such evidence will be released to the police

at this time. If I do not consent to release of evidence at this time, such evidence will be preserved at the Hospital

for not less than 30 days.

I consent to:

Physical Examination:

_____Yes

_____No

Photographing of Injuries:

_____Yes

_____No

Collection of Evidence:

_____Yes

_____No

Release of Evidence to Police:

_____Yes

_____No

Verbal Communications by

Hospital Personnel with

Prosecutorial Agency:

_____Yes

_____No

Signature of Patient______________________________________________________Date________________

Signature of Witness_____________________________________________________Date________________

Print Name of Witness____________________________________________________

LOG OF ITEMS TAKEN FROM PATIENT FOR EVIDENCE

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Sexual Assault Assessment With Consent/refusal Form And Evidentiary Log