2.  Ideally a SANE or specially trained physician for consultation and the services of a local sexual assault victim’s advocate are available

3.  The Sex Crime Victim Services Fund was designed to reimburse Indiana hospitals for the emergency care and treatment they provide to sexual assault patients

4.  If a patient of sexual assault arrives with acute medical or psychological concerns treat these immediately

5.  Although patients may not have signs of physical injuries, they will, at the very least, be suffering from emotional trauma.  Every minute spent waiting may cause valuable forensic evidence to be lost and undue stress to the patient

6.  Minimize potential embarrassment to the patient.  Avoid terms such as “rape” or “sexual assault” to identify the patient verbally

7.  If the patient must wait due to other emergencies, allow the responding officer to begin gathering pertinent information in a safe and secluded area.

8.  The importance of having a support person available to sexual assault patients cannot be overemphasized.  Whenever possible, one person should be assigned to stay with the patient throughout the entire emergency department visit.  Call the victim’s advocate as soon as the patient arrives in the ED

9.  Reporting on adult patients should be encouraged, but is NOT required  They may opt to still have a medical forensic examination performed and a sexual assault kit completed.  Other patients may only wish to receive medical treatment with no forensic examination, no evidence collection and not report to law enforcement.

10.  If the patient is under age 18, healthcare providers MUST report the sexual assault to the Indiana Department of Child Services

11.  If the patient is over 65 or considered an endangered adult, the sexual assault MUST be reported to the Adult Protective Services

12.  All procedures should be explained as much as possible  This allows the patient to understand what is being done and why  Having a sense of control is an important part of the healing process for the patient.

13.  Evidence should be collected promptly to minimize the loss of evidence  Evidence may be collected 72-120 hours after the assault  Certain extenuating circumstances may warrant that evidence collection could extend beyond 72-120 hours and should be made on a case-by-case basis and vary due to factors of the situation

14.  Prior to any evidence collection, the area should be documented and photographed

15.  A medical examination should be performed on all cases of sexual assault, regardless of the length of time that may have elapsed

16.  Sexual assault patients are trauma patients and a complete head to toe assessment should be conducted

17.  If the patient consents to prophylactic antibiotic treatment, cultures for Gonorrhea, Chlamydia and Trichomonas vaginalis do NOT need to be obtained.

18.  Non-Latex Powder-Less gloves should be worn at all times when coming in contact with the patient and/or evidence and the gloves should be changed frequently throughout the exam to prevent cross-contamination

19.  Prior to the clothing collection, determine if the patient is wearing the same clothes during or immediately following the assault  If so, all clothing should be collected  If the patient is not wearing the same clothing, inquire as to the location, such as at home in the laundry  HOWEVER THE UNDERWEAR THE PATIENT IS WEARING SHOULD ALWAYS BE COLLECTED

20.  To minimize loss of evidence, the patient should disrobe over a sheet of paper (contained in the sexual assault evidence collection kit) that is laid out over a cloth or paper sheet.

21.  If patients cannot undress on their own, or if it is necessary to cut off items of clothing, be sure not to cut through existing rips, tears, or stains

22.  If the patient arrived via EMS and was wrapped in or resting on a sheet, this sheet should be collected also

23.  Prior consent should be obtained from the patient before collecting relevant clothing as it is unlikely the clothing will be returned

24.  1. Any wet stains should be allowed to AIR DRY before being placed into paper bags  2. After air drying, items such as underwear, hosiery, slips or bras should be placed in smaller bags and items such as slacks, dresses, blouses or shirts should be put into larger bags.

25.  Each item should be placed separately in it’s own paper bag to prevent cross contamination from occurring  (This includes items such as socks)

26.  Should be collected within 24 hours  Collect 2 cotton swabs together and swan the mouth with close attention to the upper and lower lip and gum  Another tool is the 6-8 inch un-waxed dental floss, provided in the collection kit.  Once air dry, the floss should be placed into a piece of paper, folded and placed into the appropriate envelope labeled “floss”, seal and label the envelope with the collector’s initials, date and time

27.  Comb the top, back, front, and sides of the patient’s head hair over a piece of paper to collect all loose hair and debris.  Patients may prefer to do this themselves  The combings and the comb are to be folded into the piece of paper and inserted into the envelope marked “head hair combings”, Seal and label the envelope with the collector’s initials, date and time.

28.  A separate comb is used to collect any loose hair or fibers from the pubic area  This is done over a piece of paper  Patients may prefer to do this themselves  The combings should be folded in the paper with the comb and placed into the envelope marked “pubic hair combings”, sealed and labeled with the collector’s initials, date and time  **The absence of head and/or public hair should be documented**

29.  Collect if fibers or other material is observed under the patient’s fingernails  The nails should be scraped with the scraper provided in the kit  If damage is present, the nail should first be photographed, and the nail should be clipped proximally to the damage, placed in paper, and packaged in an envelope.  Seal and label with the collector’s initials, date and time

30.  Scrapings for each hand should be over a separate piece of paper  If swabs are obtained, air dry and package  Be certain to differentiate between “right hand” and “left hand”  The labeled and sealed paper folds should then be placed in an envelope labeled “fingernail scrapings”  Seal and label with the collector’s initials, date and time

31.  Collect within 72-120 hours  Swan the labia majora using 2 swabs simultaneously  Allow to air dry then package in the envelope labeled “external genitalia”  Seal and label with collector’s initials, date and time  Consider: swabbing the perineum, inner thighs, and/or behind the knees with 2 moistened swabs (using preservative free sterile water)  Allow to air dry, then package in an envelope and label the location from where the specimen was obtained, seal and label with the collector’s initials, date and time

32.  Swan labia minora using 2 swabs simultaneously  Allow to air dry then package in a blank envelope and MANUALLY label the envelope “labia minora”  Seal and label with collector’s initials, date and time

33.  Swab anal folds using 2 swabs simultaneously (using preservative free sterile water) even if anal penetration did not occur during the assault  Allow to air dry, then package in an envelope labeled “anal swabs”.  Seal and label with the collector’s initials, date and time

34.  Speculum insertion should be used with pubertal patients ONLY  DO NOT aspirate the vaginal vault or dilute the secretions in any way prior to vaginal swab collection  Use ONLY preservative free saline for speculum insertion

35.  Use 4 swabs (2 at a time) to collect additional material from the vaginal vault (2 swabs) and the cervix (2 swabs)  Make sure to collect from the cervical OS  Allow the cotton swabs to air dry, place them into the envelope labeled “vaginal/cervical swabs”  Seal and label with the collector’s initials, date and time

36.  Any medical cultures should be taken if prophylactic treatment is not intended or for other reasons deemed necessary by the healthcare provider.  All cultures are to be processed by the hospital and NOT included in the evidence collection kit.

37.  The vaginal wash should now be collected  Use 5-10 ml of preservative free sterile water and a pipette, syringe or catheter to aspirate the fluid and then place it in the red topped collection tube  Label and place the tube in bubble wrap that is provided in the collection it and then into the plastic bag labeled “vaginal washing”  Seal and label with the collector’s initials, date and time

38.  Swab the speculum with 2 sterile cotton tipped applicators  Allow to air dry, place into envelope labeled “speculum swabs”  Seal and label with the collector’s initials, date and time

39.  These must be thoroughly dried, which may take days, by air  During this time the evidence must be in a secure area  Call the local crime lab to take care of this  Once dry, the items are to be placed into an envelope or bag and labeled appropriately

40.  Slightly moisten 4 cotton swabs, 2 at a time with preservative free sterile water  Thoroughly swan the external surface of the penile shaft and glans (do not swab the urethra)  Follow culture procedures as mentioned in Female Collection

41.  Swab the anal areas by using 2 sterile cotton swabs moistened with preservative free sterile water, one at a time, swabbing just inside the anal opening and around the anal fold.  Allow to air dry, place in the paper envelope labeled “Anal Swabs”  Seal and label with the collector’s initials, date and time

42.  Examine the patient’s body for evidence of foreign matter  Swab each specimen separate  A wood’s lamp or UV light may be used at this time to scan the patient’s body to locate any possible specimens  Collect the material by gently rolling the swab over the area with a moistened swab with preservative free sterile water  Place air dried swab in an envelope  Seal and label with the collector’s initials, date and time  Be sure to indicate on the envelope the location on the patient’s body from which the specimen was collected

43.  May be difficult to distinguish due to variance of shape and size  Take photographs and collect potential saliva from the area and can be done prior to cleansing the area  Use a ruler when taking photographs to determine the size of the mark (be sure not to cover any portion of the mark)  Photographs should be released to the police investigator and made a part of the medical chart and NOT placed into the evidence kit

44.  To be used for subsequent comparison with stains and the assailant’s blood standard  Check the expiration date on the blood tube  If it is expired replace with the hospital's equivalent tube  For adults 5-7 ml of blood should be collected in a purple top EDTA blood tube, labeled with the identifying information.  Label the blood tubes with the collector’s initials, date and time  Seal the whole blood samples in bubble wrap, place them in the provided zip lock bag and keep with the kit refrigerated but not frozen  **DO NOT collect from children or adolescents unless blood samples are needed for medical purposes**

45.  Information and referrals for STD’s (STI’s) should be provided to the patient as part of their discharge instructions  Additional testing should be done according to the policy of the individual healthcare facility.

46.  Do NOT package in plastic, this may result in evidence contamination  Always package using the paper bags, it allows the evidence to “breathe”

47.  Chain of custody is VITALLY IMPORTANT  Anyone who handles the evidence should label them with their initials, ate and time, source of specimen and the name of the patient  Each envelope should be labeled and sealed with patient labels or tape  DO NOT LICK THE ENVELOPES!!! Use tap water to seal

48.  Document as completely as possible in the medical record  A thorough complete and legible medical record with accompanying body diagram will assist the healthcare provider when recalling the case  Be careful not to include any subjective opinions or conclusions  Avoid using the term “rape” or “sexual assault” on the medical document-it is a legal conclusion  Avoid the term “allegedly”  It is acceptable to use “reported sexual assault or Sexual assault by history”

49.  Date and time of Collection  Date and time of Assault  Assailants  Post Assault History  Contraceptive / Menstruation Information  History of the assault  Geographical Location of the Assault  Physical Examination Details

50.  Contraception / Menstruation Information  History of the assault  Geographical Location of the Assault  Physical Examination Details  Date of Last Consensual Sexual Activity

51.  Medical History  Gynecological History  Sexually Transmitted Infections  HIV Testing

52.  MUST be kept separate both in terms of collection and processing  Required strictly for forensic analysis and should be collected using the sexual assault evidence collection it and protocol

53.  Place all specimens back into the kit  Make certain that everything is properly labeled and sealed  Include a copy of the Indiana Sex Crime Victim Compensation Form  DO NOT include any documentation in the kit  The kit should be in a locked, secured area and refrigerated including any bagged clothing

54.  Should be released to the jurisdictional law enforcement agency representative  The rep should date and time and sign the form as well as complete the information on the top of the evidence collection box.  The yellow copy of the Sex Crime Application should be given to the law enforcement and the hospital retains the white copy and pink copy

55.  ONLY a law enforcement officer or duly authorized agent should transfer physical evidence from the hospital to the crime lab for analysis  Under no circumstances should the patient be allowed to handle the evidence after it has been collected

56.  Never react negatively to a patient’s choice to not release the evidence to law enforcement  The victim has one year to decide if they wish to report the crime  Law enforcement will store and refrigerate the kit for the one year and they will determine how to label and identify the kit

57.  Medical and counseling follow up options should be discussed before the patient is discharged  Encourage the patient to pursue follow up testing and seek treatment for symptoms  Include contact information for follow up  Provide informational brochures with the same information  If possible, allow the patient to shower or “clean up” after the procedures and examinations are complete