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Suspected Offender Consent Form
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In-Take Information
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SANE Nurse
• • •
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Date of Exam
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Exam Start Time
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Responding L. E. & Case Number
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Name of Officer/Detective Present
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Search Warrent Reviewed
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Copy of Search Warrant Obtained
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Date of Assault
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Time of Assault
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Location of Assault
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Comments
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Suspected Offender Information
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Height
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Weight
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Build
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Eye Color
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Hair (Color/Style)
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Complexion (Smooth, Acne, Etc.)
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Complexion Color
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Right Handed or Left Handed
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Features (Tattoos, Scars, Piercing Etc.)
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Ethnicity
• • •
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Other Ethnicity
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Language
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Interpreter
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Recent Medical History
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Consensual sex in last 5 days?
• • •
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Any pre-existing physical injuries?
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If yes, describe:
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Any recent Anal-Genital Injuries?
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If yes, describe:
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Any recent surgeries?
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If yes, describe:
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Any recent procedures/treatments?
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If yes, describe:
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Any other pertinent medical conditions?
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If yes, describe:
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Post-Assault Hygiene Activity
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Defecated
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Urinated
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Ate
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Drank
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Smoked
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Changed Clothing
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Showered/Bathed
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Brush Teeth/Gargled
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Chewed Gum
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Other
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Demeanor/Behavior
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Eye Contact
• • •
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Other
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Behavior
• • •
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Other
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Speech
• • •
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Other Comments for Demeanor
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Non-Verbal Expressions/Behaviors
• • •
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Responsive to Clinician
• • •
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Speech
• • •
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Appearance
• • •
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Comments on Appearance/Clothes
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Physical Assessment
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Current Immunization Status
• • •
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Past Medical History
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Past Surgical History
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General Assessment~Normal
• • •
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General Assessment~Abnormal
• • •
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Additional General Comments
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Head Assessment~ Normal
• • •
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Head Assessment~Abnormal
• • •
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Additional Head Comments
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Eye Assessment~Normal
• • •
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Eye Assessment~Abnormal
• • •
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Additional Eye Comments
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Ears Assessment~Normal
• • •
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Ears Assessment~Abnormal
• • •
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Additional Ears Comments
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Nose Assessment~Normal
• • •
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Nose Assessment~Abnormal
• • •
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Additional Nose Comments
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Oropharynx Assessment~Normal
• • •
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Oropharynx Assessment~Abnormal
• • •
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Additional Oropharynx Comments
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Neck Assessment~Normal
• • •
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Neck Assessment~Abnormal
• • •
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Additional Neck Comments
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Cardiovascular Assessment~Normal
• • •
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Cardiovascular Assessment~Abnormal
• • •
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Additional Cardiovascular Comments
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Pulmonary Assessment~Normal
• • •
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Pulmonary Assessment~Abnormal
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Additional Pulmonary Comments
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Abdomen Assessment~Normal
• • •
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Abdomen Assessment~Abnormal
• • •
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Additional Abdomen Comments
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Skin Assessment~Normal
• • •
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Skin Assessment~Abnormal
• • •
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Additional Skin Comments
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Musculoskeletal Assessment~Normal
• • •
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Musculoskeletal Assessment~Abnormal
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Additional Musculoskeletal Comments
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Breast/Chest Assessment~Normal
• • •
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Breast/Chest Assessment~Abnormal
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Additional Chest/Breast Comments
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Upper Extremities Assessment~Normal
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Upper Extremities Assessment~Abnormal
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Additional Upper Extrem Comments
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Lower Extremities Assessment~Normal
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Lower Extrem Assessment~Abnormal
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Additional Lower Extrem Comments
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Neuro Assessment~Normal
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Neuro Assessment~Abnormal
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Additional Neuro Comments
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Psychiatric Assessment~Normal
• • •
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Psychiatric Assessment~Abnormal
• • •
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Additional Psychiatric Comments
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Suicide Assessment
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Emergency Services Referred/Required
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Clothing
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Clothing Collected
• • •
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Clothing Information
• • •
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Clothing Description
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Photos of Clothing
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Additional Comments About Clothing
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Number of Photos
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Type of Film
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Other Evidence
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Alternative Light Source Used
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Type of ALS
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If (+), describe:
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Environmental Debris
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If yes, describe:
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Fingernail Evidence
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If yes, describe:
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Misc. Evidence
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If yes, describe:
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Any pertinent comments made by Suspect?
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Genital Map
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Penis Circumcised
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Glans
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Comments
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Urethral Meatus
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Comments
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Scrotum
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Comments
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Shaft
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Comments
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Photo Information
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Comments
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Photo of Clothes
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If yes, approximate number of photos:
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Photos of Body
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If yes, approximate number of photos:
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Photos of Genitalia
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If yes, approximate number of photos:
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Type of Film
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Sexual Assault Suspect Exam Check List
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Progress Notes
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Progress Notes
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Penis and Anus
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Penis and Anus: Additional Comments
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Male Body (Front & Back)
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Male Body (Front & Back): Comments
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Male Body (Lateral)
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Male Body (Lateral): Comments
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Male Face (Front & Back)
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Male Face (Front & Back): Comments
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Male Face (Lateral)
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Male Face (Lateral): Comments
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Mouth
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Mouth: Additional Comments
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Hands
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Hands: Additional Comments
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Feet
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Feet: Additional Comments
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