Colorado Sexual Assault Consent And Information Form

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COLORADO SEXUAL ASSAULT
CONSENT and INFORMATION FORM
Collection, Analysis/Release, and Consent Withdrawal of Sexual Assault Evidence/Information
 You have the right to have this form explained and all of your questions answered.
Please initial and sign where appropriate. You will receive a copy of this form after it is completed.
Law Enforcement Agency:
Case No:
Officer Name:
Phone No:
Medical Forensic Exam
I consent to a medical forensic exam. I understand I can stop the exam at any time and can decline
any portion of the exam or collection of any sample.
 ________
Reporting Decision
(initial only one)
I am choosing to make a report to law enforcement. I give permission for evidence collected and
information gathered during my sexual assault exam to be released to law enforcement for use in
 ________
investigation(s) and potential prosecution(s). I understand the investigating law enforcement agency
will be given my name and contact information.
At this time, I am choosing NOT TO REPORT TO LAW ENFORCEMENT OR PARTICIPATE in any
investigation. I understand I can change my mind and later report to law enforcement. I understand
 ________
law enforcement may be given my name. I understand law enforcement may choose to investigate
but I do not have to participate.
Evidence Analysis/Release of Results
(initial only one)
I consent for law enforcement to release the collected evidence to a forensic lab for analysis.
I understand law enforcement may submit the evidence to a lab no later than 21 days after receiving it.
 ________
I understand if the evidence is analyzed, law enforcement will receive the results for the purposes of
investigation(s) and potential prosecution(s).
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 the evidence analyzed at a forensic lab.
I understand law enforcement is only required to hold the evidence for a minimum of 2 years.
Withdrawal of Consent for Evidence Analysis/Release of Results
(only patients 18 years & older)
I understand I may withdraw my consent for evidence analysis/release of results by contacting the
law enforcement agency listed on this form. I understand the withdrawal of consent becomes
 ________
effective when law enforcement verifies my identity, but will not apply to any actions already taken.
I understand that once analysis has begun, consent cannot be withdrawn.
Printed Patient Name
Patient Signature
Date
Printed Witness Name/Title
Witness Signature
Date
 
White Copy – Enclose with Kit
Yellow Copy - Law Enforcement
Pink Copy – Medical Records
Green Copy – Patient

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