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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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Present During Exam
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Police Report
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Responding Law Enforcement
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Case Number
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Officer/Detective Present
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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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Suspect Information
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Suspected Offender's Name
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DOB
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Age
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Gender
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Ethnicity
• • •
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Other Ethnicity
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Height
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Weight
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Build
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Hair (Color/Style)
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Eye Color
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Complexion Color
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Complexion (Smooth, Acne, Etc.)
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Features (Tattoos, Scars, Etc.)
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Right Handed or Left Handed
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Language
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Interpreter
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Agency/Phone
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Consensual Sex in Past 5 days?
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Recent Medical History
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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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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
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Comments on Appearance/Clothes
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Other Comments for Demeanor
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Physical Findings
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Past Medical History
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Past Surgical History
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ABCs
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Comments
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Skin
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Comments
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Oral
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Comments
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Cardiovascular
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Comments
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Pulmonary
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Comments
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Abdomen
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Comments
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Other
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Body Surface Injuries
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Comments
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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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Additional Comments About Clothing
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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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Mons Pubis
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Comments
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Liba Majora
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Comments
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Labia Minora
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Comments
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Clitoris
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Comments
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Urethral Meatus
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Comments
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Vestibule Anterior
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Comments
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Vestibule Posterior
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Comments
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Hymen
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Comments
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Fossa Navicularis
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Comments
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Posterior Fourchette
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Comments
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Perineum
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Comments
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Cervix
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Comments
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Vagina
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Comments
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Photo Information
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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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Suspected Offeneder Form
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Progress Notes
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Progress Notes
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Time
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Vagina and Anus
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Vagina and Anus: Additional Comments
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Breasts
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Breasts: Additional Comments
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Female Body (Front & Back)
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Female Body (Front & Back): Comments
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Female Body (Lateral)
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Female Body (Lateral): Comments
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Female Face (Front & Lateral)
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Female Face (Front & 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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