4.4.1.1 Sexual Assault History Form

Obtain a history of the assault and other relevant data as directed by the enclosed ‘Sexual Assault History Form’.

Complete as much information as possible on the form.

Print clearly and legibly.

When asking the patient to give a description of the assault, DO NOT ASK LEADING QUESTIONS that direct the survivor towards yes or no answers, such as “Were you raped?”

Instead, ask the patient, “What happened?” or “Can you describe the incident to me?”

Let the patient use their own words, and use those words in your charting.

Documentation of the patient’s account of the assault must be the patient’s verbatim statement. Use quotations to indicate the patient’s actual statements.

It’s critical that no re-phrasing occur.

Let the patient know that for evidence collection, you need to ask specific questions about which of the perpetrator’s body parts touched the patient’s body parts.

This history is for diagnosis and treatment of the patient and to direct the collection of evidence. LAW ENFORCEMENT WILL DO THE INVESTIGATIVE INTERVIEW.

The examiner should avoid using the word ‘rape’ in discussing any conclusions. Use the words “sexual assault” or “assault.”