Connecticut 100 Forms

General Information

  • The CT100 Sexual Assault Forms (seven pages) should be completed whenever a sexual assault examination is performed, whether or not the CT100 Sexual Assault Evidence Collection Kit is completed.
  • A reasonable supply of Forms should be maintained by each health care facility for the documentation of sexual assault examinations in situations in which the kit is not opened.
  • A complete set of Forms includes a four-page Medical Report, one page Checklist, and one page Discharge Instructions. These Forms are contained in each sealed Kit.
  • Hospital Billing Personnel may contact the Office of Victim Services with billing questions. (See appendix G).

Use as Medical Record

  • The original copy of the Forms (all white pages) shall be retained as part of the patient’s medical record. (See pages 18 and 19 for instructions regarding distribution of yellow copies of pages one and six).
  • The Forms may be supplemented with other documentation as deemed appropriate, such as triage forms, patient property release forms, etc.

General Instructions

  • Imprint each of the six pages in the upper right corner with patient’s identification information plate/card. If imprinting is not available, legibly handwrite the requested information in the space provided.
  • Write clearly and legibly to enable others to read and understand your writing.
  • Wherever boxes are provided for responses, be careful to confine the response mark to the appropriate box.
  • Avoid using judgmental statements and/or the word “alleged”. Record your observations and the patient’s statement without including your opinions, values or your own personal statements.
  • Wherever space is provided for written responses record the patient’s response in her/his own words, especially in Section 2C of the Medical Report.
  • Additional space for written responses is provided in Section 9 of the Medical Report. If more space is required, use additional sheets as needed and attach them to the Medical Report.
  • Clarify any unclear responses given by the patient to ensure that you understand and record the response properly.
  • Avoid asking the patient to repeat her/his account of the assault numerous times (e.g., to nurse, physician, social worker).
  • At all times, respect the patient’s right not to answer any or all questions.
  • If the patient choose to skip a step of the kit, write “declined” rather than “refused” on the reporting forms.

Completion of Medical Report (See sample at pages 22 through 25).

Specific Instructions

  • In Section 2 of the Medical Report record patient’s account of the sexual assault, including information such as gender of assailant, and number of assailants, etc.
  • If information requested in Section 2 of the Medical Report is recorded elsewhere, such as on a physician’s consult form, include a copy of that form with the yellow copy of page 1 in the envelope on the Kit box bottom.
  • In Section 2 of the Medical Report ask specifically about contact, penetration and ejaculation.
  • In Section 3 of the Medical Report document other sexual activity of the patient only if it occurred within 120 hours prior to the assault.
  • In Section 3 of the Medical Report record medical history such as present illnesses, medications, drug allergies, gynecological history, etc.
  • In Section 4 of the Medical Report provide a detailed description of the patient’s outward appearance.
  • In Section 4 of the Medical Report provide details regarding any marks, bruises, etc. on the patient’s body. Be sure to indicate the location on anatomical drawings.
  • In Section 5 of the Medical Report provide details regarding any injuries and/or signs of trauma in the area of the patient’s genitalia. Drawings are important even if photographs are taken. (See page 50 for information regarding photographs).
  • In Section 5 of the Medical Report provide details regarding the patient’s observable behavior during the examination.
  • In Section 8 of the Medical Report record impression/diagnosis (e.g., “sexual assault by History,” or “examination and history consistent with patient’s complaint of sexual assault”).
  • Section 9 should be completed to indicate whether photographs were taken. (See page 50 for information regarding photographs).
  • Section 9 should be completed to indicate whether a forensic odontologist was consulted. If “Yes” is checked, record details, including the name of the odontologist, in section 9.
  • Section 9 of the Medical Report should be completed by the nurse/physician and the officer who completed the transfer, respectively, when collected evidence is transferred to police custody.

Necessary Signatures

  • The nurse or physician completing each designated group of sections should sign or write her/his name on the appropriate lines as required by the Medical Report form.
  • The signature section following Section 9 of the Medical Report should be completed by all medical personnel who participated in the completion of the Medical Report.
  • If an interpreter was involved in the translation of the questions and/or responses contained in the Medical Report, print that person’s name, address and phone number in the spaces provided following Section 10.
  • When evidence is transferred to police custody, the nurse/physician and the officer who completed the transfer should complete Section 9 of the Medical Report. (See page 62-64).

Distribution of The Medical Report

  • When all pages of the Medical Report are completed, place the white copies (and any supplemental pages) in the patient’s medical record, and place the yellow copy of the first page (and copies of any supplemental pages) in the envelope on the bottom of the Kit box.
  • If a Kit is not completed, place all pages in the patient’s medical record.

Completion of Discharge Instructions (page 6) (See sample at page 26).

Specific Instructions

  • Whenever a sexual assault patient is discharged from the hospital or transferred to an inpatient department, the Discharge Instructions should be completed and a copy should be given to the patient.
  • Legibly complete all sections of the Discharge Instructions and provide all relevant information. This information may be helpful to the patient and/or the provider of follow-up care.
  • Review all information recorded on the Discharge Instructions with the patient or responsible party during discharge.
  • In Section 1 of the Discharge Instructions be sure to explain to the patient that the tests s/he received will only tell whether s/he had the disease/condition prior to the assault and hospital visit. Explain that follow-up testing must be done to determine whether a disease/condition was contracted during the assault.
  • In Section 2 of the Discharge Instructions note the name and dose of any medications administered or prescribed. Emphasize the need to take and finish all medications as prescribed.
  • In Section 2 of the Discharge Instructions explain that medications were given prophylactically, and stress the need for follow-up care.
  • In Section 3 of the Discharge Instructions stress the need to refrain from sexual relations until follow-up care has been received.
  • In Section 3 of the Discharge Instructions be sure that the patient, patient’s representative or responsible party understands that s/he is responsible for scheduling follow-up care.
  • In Section 3 of the Discharge Instructions provide the telephone number of the sexual assault crisis services Hotline (See page 69 for Referral and Assistance information).
  • In Section 3 of the Discharge Instructions provide information regarding available sexual assault crisis services, even though the patient may choose to consult a private mental health provider, or no one.
  • In Section 3 of the Discharge Instructions legibly write instructions regarding testing for HIV, including the location and telephone number of an anonymous/confidential HIV counseling and testing facility in the patient’s area. (See Appendix G for listing of counseling and testing facilities). (See also page 58 for information regarding HIV testing of sexual assault patients).
  • In Section 3 of the Discharge Instructions legibly write any additional instructions or information, as appropriate use additional paper as needed, keeping a copy for the medical record and providing the patient with a copy.
  • In Section 3 of the Discharge Instructions note that the booklet, Information for Victims of  Sexual Assault and Their Families, was given to the patient.
  • In Section 4 of the Discharge Instructions legibly complete all categories of information for the patient’s reference as follows:
    • Provide the facility name, the name of one provider/examiner the patient can contact with further questions/problems, and the telephone number s/he can use to make that contact;
    • Provide the name and telephone number of the local sexual assault crisis service program. (See Appendix D)
    • Provide the name, town or troop, and telephone number of the police officer who responded and/or took custody of evidence;
    • Provide any other contact names and numbers discussed with the patient;
    • Record the “Control Number” (see below) used to identify any collected evidence if the patient decides not to report the incident to the police at the time.

Control Number

  • Whenever a sexual assault patient is undecided about whether to report the assault to the police, a control number – in place of the patient’s name or medical record number – must be used on the external identification labels of the evidence containers (e.g., the Kit box and clothing bag(s)).
  • The step envelopes inside the Kit box and the small white clothing bags inside the large brown clothing bag should always be labeled with the patient’s name and other requested information even if the control number will be used on external identification labels.
  • Control Number specifications should be noted in Section 4 of the Discharge Instructions as follows:
    • The name of the health care facility, followed by a colon;
    • The patient’s initials, followed by a colon;
    • The six-digit discharge date;
    • Hospital Name: ABC: mm/dd/yy.
    • For example, if a patient named Anne Marie Smith had a kit completed at Hartford Hospital on July 17, 20013, the control number would be: HartfordHospital:AMS:07/17/13

Necessary Signatures

  • In Section 5 of the Discharge Instructions, after discussing the recorded information with the patient and providing an opportunity for the patient to read the form and to ask questions, if necessary, the following should be completed:
    • The patient or the patient’s representative (parent or guardian) should sign the form in the appropriate space provided;
    • The examiner completing the Discharge Instructions should sign the form in the appropriate space provided;
    • The date and time of discharge should be entered in the space provided.

Distribution of Discharge Instructions

  • When the Discharge Instructions have been completed and all necessary signatures have been attached, distribute the copies as follows:
    • The yellow copy of the Discharge Instructions should be given to the patient. S/he should be advised to bring that copy to follow-up visits;
    • The white copy of the Discharge Instructions should be placed in the patient’s medical record.

Completion of Checklist (See sample at page 27).

Specific Instructions

  • Use the Checklist as a guide while completing the sexual assault examination to ensure that important steps are not overlooked.
  • Check-off completed and/or purposely not completed steps listed on the Checklist during the examination to ensure that all evidence is collected.
  • Record comments in the space provided on the Checklist during the examination to ensure that important information is not forgotten.
  • If a step listed on the Checklist purposely was not completed, indicate reason/situation in the “comments” section (e.g, N/A, patient declined, etc.).
  • Use line 19, “Other,” to record any completed step or procedure not listed on the Checklist (e.g., reporting gunshot victim to police).
  • Follow your facility’s guidelines regarding mandatory reporting policies and procedures. (See  also page 4 and Appendix F for information about mandatory reporting).

Necessary Signatures

  • The examiner responsible for the examination should sign the Checklist in the space provided.

Completion of Checklist (Page 5 of Medical Forms)

  • When the Checklist has been completed, place it in the patient’s medical record, not in the kit.
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