General information

Demographic data about the patient

Name, address, and phone number of the guardian if the patient is under age

Name of police officer, badge number, and department

Date, time, and location of examination

History

Circumstances of attack, including

• Date, time, and location

• Information about assailants (number, name if known, description)

• Use of threats, restraints, or weapon

• Type of sexual contact (vaginal, oral, rectal; use of condom)

• Types of extragenital injuries sustained

• Occurrence of bleeding (patient or assailant)

• Occurrence and location of ejaculation by the assailant

Activities of the patient after the attack, such as

• Douching or bathing

• Use of a tampon or sanitary napkin

• Urination or defecation

• Changing of clothing

• Eating or drinking

• Use of toothpaste, mouthwash, enemas, or medications

Last menstrual period

Date of previous sexual activity and time, if recent

Contraceptive history (eg, oral contraceptives, intrauterine device)

Physical examination

General (extragenital) trauma to any area

Genital trauma to the perineum, hymen, vulva, vagina, cervix, or anus

Foreign material on the body (eg, stains, hair, dirt, twigs)

Examination with Wood’s lamp or colposcopy when available

Data collection

Condition of clothing (eg, damaged, stained, foreign material adhering)

Small samples of clothing, including an unstained sample, given to the police or laboratory

Hair samples, including loose hairs adhering to the patient or clothing, semen-encrusted pubic hair, and clipped scalp and pubic hairs of the patient (at least 10 of each for comparison)

Semen taken from the cervix, vagina, rectum, mouth, and thighs

Blood taken from the patient

Dried samples of the assailant’s blood taken from the patient’s body and clothing

Urine

Saliva

Smears of buccal mucosa

Fingernail clippings and scrapings

Other specimens, as indicated by the history or physical examination

Laboratory testing

Acid phosphatase to detect presence of sperm*

Saline suspension from the vagina† (for sperm motility)

Semen analysis for sperm morphology and presence of A, B, or H blood group substances‡

Baseline serologic test for syphilis in the patient§

Baseline testing for other sexually transmitted infections in the patient§

Blood typing (using blood from the patient and dried samples of the assailant’s blood)

Urine testing, including drug screen|| and pregnancy test

Other tests, as indicated by the history or physical examination

Treatment, referral, physician’s clinical comments

Documented in the medical record

Witness to examination

Signature on any required forms

Disposition of evidence

Name of the person who delivered the evidence and the person who received it

Date and time of delivery and receipt