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.