Reset Form Print Form

SAFE CONSULTANT INFORMATION

SEXUAL ASSAULT FORENSIC EXAMINER INFORMATION

Facility Name: State Institution Private Practice

Facility Address:

Facility Phone number: Forensic Examination Hours:

Full Name of Official Forensic Examiner:

Cell phone number: After regular hours contact information:

Email address:

Other SAFE examiners who share duty/call:

FACILITY INFORMATION
# of examination rooms

Privacy of exam rooms

Cleanliness of exam rooms

Jurisdiction this facility covers for SAFE exams:

Associated with a hospital for admittance if injuries necessitate

SEXUAL ASSAULT FORENSIC EXAM (SAFE) INFORMATION

Describe the procedures for a SAFE in this country:

Requires police/investigator/court order for SAFE to be performed?

Could a Volunteer receive a SAFE exam without launching an investigation?

9/1/13 TG540 Attachment K

 SAFE CONSULTANT INFORMATION

Can the Volunteer stop the exam at any time during the exam?

If it is legal for the PCMO and/or support person in the room with the Volunteer during the SAFE, will the examiner
allow these support people in the exam room ?

Does the SAFE require a physical exam? If so, how long does it typically take?

Do you photograph wounds? If so, where are those photographs maintained?

Does the facility use a sexual assault kit for evidence collection?

Would you like Peace Corps to provide the SAK for a Volunteer who requires a SAFE?

What instruments are used during the exam and how are they sterilized by the facility?

Provides medical services in conjunction with the SAFE exam (e.g. emergency care, suturing, surgery, etc.)?

If laboratory specimens are obtained to identify sexually transmitted infections, pregnancy, HIV, where are they
processed?

Do you get permission from the victim to test for drug facilitated sexual assault? What toxicology laboratory do
you use?

Do you assess for and presumptively treat sexually transmitted infection exposure (gonorrhea, syphilis, Hepatitis B,
Hepatitis C) related to the assault? If yes, which infections and medications are used?

Do you assess for HIV exposure risk and presumptively treat HIV exposure related to the assault? If yes, which
prophylactic treatment is used?

Do you test for pregnancy risk and provide pregnancy prevention medication related to the assault. If yes, which
prophylactic treatment is used?

Can you provide a copy of the examination to the Peace Corps for the Volunteers medical file?

9/1/13 TG540 Attachment K

 SAFE CONSULTANT INFORMATION

FORENSIC EXAMINER TRAINING AND BACKGROUND

Nationality:

Specialty:

Credentials (MD, RN, Tech, etc.)

Medical/Nursing School name: Year completed:

Certified To Perform SAFEs?

English Skill:

Does this consultant have hospital admitting privileges? If yes, where?

Impression of consultant: appearance, demeanor, response to questions, openness, willingness to work with PC,
clinical competence.

Comments/Notes:

PCMO completing form: ___________________________Date Completed:________________

9/1/13 TG540 Attachment K