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.