Peace Corps Clinical Sexual Assault

Examination Instructions (Attachment G)

REQUIRED USE OF STANDARD FORM
Peace Corps requires that a Peace Corps Medical Officer who conducts a medical examination of a Peace Corps Volunteer
who is a victim of sexual assault use a standard form to record findings to guide clinical care. The end of the form has a
place to document forensic evidence collected in the event that the PCMO is authorized to do so.

LIABILITY AND RELEASE OF INFORMATION

This medical report is subject to the confidentiality requirements of the Medical Information Act (Civil Code Sec. 56 et
seq.), the Physician-Patient Privilege (Ev. Code Sec. 990), and the Official Information Privilege (Ev. Code Sec.1040). It can
only be released to those involved in the clinical management of the Volunteer or to the defense counsel only through
discovery of documents in the possession of a prosecuting agency after the appropriate court process (i.e., judicial review
and a court order).

CONSENT FROM VOLUNTEER

The PCMO must obtain written consent from the Volunteer before taking the history, performing a clinical exam,
collecting laboratory specimens, taking photographs, or collecting evidence in conjunction with this exam.
.
Complete this report in its entirety. Use N/A (not applicable) when appropriate to show that the PCMO attended to all questions.
Explain what is going to happen during each step of the exam to the Volunteer. If the Volunteer asks, explain why it is important, what
it will tell the examiner and how the PCMO will use the information obtained during the exam to determine what treatment and other
steps are appropriate. Reassure the Volunteer that she is in control of the pace, timing, and components of the exam.

A. VOLUNTEER DEMOGRAPHICS:
1. Enter the patient's name and identification number (if applicable) and reporting preference at the time of the exam.
2. Print or type the name of the Peace Corps Medical Officer that conducted the exam and the post where
the exam was conducted.
3. Enter the patient's age, date of birth (DOB}, gender, and ethnicity; and date/time of exam.

B. INITIAL ASSESSMENT:
Initial primary assessment may reveal severe medical complications that need to be treated urgently. Such
complications might include: extensive trauma to genitals, head, chest or abdomen, neurological deficits, and/or
respiratory distress.
1 . Record vital signs and height and weight.
2. Describe the Volunteers pain level on a scale of 0 to 10 with 0 being no pain and 10 being worst pain.

C. ASSAULT HISTORY
Interview the fully-dressed Volunteer in the examination room. Use a calm tone of voice and maintain eye contact.
Speak clearly and directly to the Volunteer. Do not stand over the Volunteer. Sit equal or lower than the level of the
Volunteer and begin gathering the medical history.

1. Enter date and time of the assault(s)

2. Describe the pertinent physical surroundings that may have come in contact with the patient.
3. Describe the Incident
Allow the Volunteer tell the history of events the way she wants to. Do not interrupt. Explain that she does
not have to tell you anything that she is not comfortable with. Examples of appropriate interview
questions:
Tell me what happened. Please tell me everything you remember about what happened. Describe to me
what happened in the best way that you can. I know these are hard questions , but in order for me to
understand the care you will need, I need to ask you more details about this. I will go as fast as I can.
Please explain any involvement of your body (e.g. mouth, vagina, anus, and breast).
Can you tell about what happened here (PCMO points to wound)?
Are there any parts of the incident that you have difficulty remembering?
Is there anything that I did not ask you that you would like to tell me?
Can you describe what you were thinking or feeling during the incident?
 Document what happened using the patient's own words including the history of events, threats made against
her and name(s) of assailant(s). Use qualifying statements such as: Volunteer states or Volunteer reports
and place quotation marks around the patient's comments Do not sanitize or remove remarks such as slang,
offensive, or derogatory statements.

4. Describe the methods employed by the assailant(s)

Complete this section by checking "yes" or "no" in the appropriate boxes.
The drug/alcohol questions help assess how and which medications should be offered for treatment.
5. Penetration of vagina or penis
Mark the appropriate box for each method of penetration of the vagina. Mark "attempted" if it is reasonably clear, based upon the patient's
statement, that the assailant(s) intended an act but was thwarted by the patient, an intervening occurrence, or was unable to accomplish the act.
6. Penetration of anus
Mark the appropriate box for each method of penetration of the anus/rectum. Mark "attempted" if it is reasonably clear, based upon the patient's
statement, that the assailant(s) intended an act but was thwarted by the patient, an intervening occurrence, or was unable to accomplish the act.
7. Oralcopulation of genitals
Mark the appropriate box. Mark "attempted" if it is reasonably clear, based upon the patient's statement, that the assailant(s) intended an act but
was thwarted by the patient, an intervening occurrence, or was unable to accomplish the act.
8. Oralcopulation of anus
Mark the appropriate box. Mark "attempted" if it is reasonably clear, based upon the patient's statement, that the assailant(s) intended an act but
was thwarted by the patient, an intervening occurrence, or was unable to accomplish the act.
9. Non-genital act(s)
Mark the appropriate box. If yes, describe the act and note where it occurred on the adjacent line. Mark "attempted" if it is reasonably clear, based
upon the patient's statement, that the assailant(s) intended an act but was thwarted by the patient, an intervening occurrence, or
was unable to accomplish the act. Note: The term suction injury means "hickey".
10. Record any other act(s).
Provide a description in the adjacent space.
11. Did ejaculation occur?
Mark the appropriate box.
12. Contraceptive or lubricant products
Note whether a contraceptive or a lubricant product was used during the assault. If yes, record the type if known.

D. VOLUNTEER HISTORY
1. Document any current form of birth control if applicable
2. Obtain pertinent medical history.
For females: Record the date of the last menstrual period. This information is used to determine whether the patient was menstruating at
the time of the examination and to evaluate the possibility of pregnancy and post coital options.
Obtain recent (past 60 days) information on any anal-genital injuries, surgeries, diagnostic procedures, or medical treatment that may
affect the interpretation of current physical findings. This information is requested to avoid confusing preexisting lesions with injuries or
findings related to the alleged assault.
Describe any other pertinent medical conditions that may affect the interpretation of current physical findings.
Describe any pre-existing physical injuries.
3. Obtain assault-related history.
If any of the boxes are marked "yes", use the space provided to describe.
The pain and bleeding questions direct the health care professional to look for injury and evidence not readily visible.
4. Obtain pertinent pre- and post-assault related history.
Ask whether the patient has had sexual contact within the past 5 days. If yes, describe. Do not record any other information
regarding sexual history on this form.
Record whether there was any voluntary drug/alcohol use prior to the alleged assault and any drug/alcohol use since the assault. If
yes, describe. (Asking about alcohol is sensitive and it is important not to imply blame. Tell the Volunteer that
the history of alcohol consumption is important especially when providing prophylactic medications that may
react adversely with alcohol. If the Volunteer shows signs of being uncomfortable with the response to this
question, reassure her that alcohol consumption will not be used to accuse or blame her for the assault.

Appropriate question to ask:

When was the last time you had an alcoholic drink as this might affect the treatment plan?
E. MENTAL HEALTH STATUS
The Mental Health Assessment requires a PCMOs observations and the Volunteers responses to a series of questions.
Refer to TG 545 for further information.
1. Volunteers appearance (choose all that apply)
2. Volunteers behavior (choose all that apply)
3. Volunteers speech (choose all that apply)
4. Affect (choose all that apply)
5. Mood: Ask, How are you feeling? Document Volunteers response in quotations in space provided
6. Suicidal: Ask, Do you have feelings of wanting to hurt yourself?
i. If yes, ask, Do you have a plan on how you would hurt yourself?
ii. If yes, ask, What is the plan and do you have access to the method (weapon, drugs, rope, etc.)?
7. Homicidal: Ask, Do you have feelings of wanting to hurt someone (e.g. assailant)?
i. If yes, ask, Do you have a plan on how you would hurt someone?
ii. If yes, ask, What is the plan and do you have access to the method (weapon, drugs, etc.)?
8. Thought Processes: (choose one)
9. Thought Content
i. Hallucinations: (choose all that apply)
ii. Delusions: (choose all that apply)
iii. Perceptions: (choose all that apply)
10. Orientation to person, place and time (do they know who they are, where they are, and the date/time).
11. Consciousness: (choose all that apply)

F. PRIMARY CARE PTSD SCREEN (PC-PTSD)

The ASD/PTSD Screening requires the Volunteers responses to these screening questions. This is indicated if the
Volunteer is experiencing any of the responses in these screening questions. Refer to TG 545 for score results and
treatment suggestions. If it is not appropriate to ask questions that do not pertain to the situation, it is okay to skip that
question (e.g. asking about nightmares if the event took place 2 hours prior to the exam, etc)
1. Re-experiencing: Yes or No to flashbacks, intrusive thoughts, or nightmares
2. Avoidance: Yes or No
3. Increased Arousal: Yes or No
4. Dissociative Symptoms: Yes or No

G. GENERAL PHYSICAL EXAMINATION AND DOCUMENTATION.

DOCUMENTATION OF INJURIES AND FINDINGS USING DIAGRAMS AND LEGEND

If the sexual assault does not warrant an examination or the Volunteer declines an exam, indicate
accordingly in the boxes allotted.
Physical Findings: A physical finding includes observable or palpable tissue injuries, physiologic changes,
or foreign material (e.g. grass, sand, dirt). If none of the above are present, mark "No Findings". During
the physical examination, look for pattern injuries associated with the history of events and physical
surroundings in which the assault took place.
Record size and appearance of injuries and other findings using the diagrams, the legend, and a
consecutive numbering system.
How to use the diagrams, legends and numbering system: Diagram letter+wound number+ abbreviation
for type of wound. Use the abbreviations in the legend to describe the type of finding. Example: A-1, EC
2x3cm red/purple indicates that the first finding on Diagram A is an ecchymosis (bruise) that is
red/purple in color and 2x3 centimeters in size. See example below.

Locator# & Type Description

A-1 EC 2x3 em red/purple
A-2 OS Dried secretion
A-3 CS Control swab
 If completing form by hand, blue ink is preferred, but black ink acceptable. If an error is made in
documentation, strike through with one line and write inaccurate entry, date, and initial. Do not write
error, erase, or completely black out, or use white out liquid on the document.
Document findings without stating conclusions about the nature of the incident as a rape or sexual
assault. It is not the PCMOs responsibility to determine the legal finding of rape or sexual assault.
Document exactly what you see as a clinician, not what you think/presumed happened.

Standardized Term Definition/Description

for Wound
Laceration/Tear Blunt force trauma to tissue that occurs from crushing impact resulting in an open wound
with irregular edges or margins.
Incision Disruption of skin with smooth, clean demarcated edges caused by sharp force trauma
(e.g. broken glass, knife, paper).
Bruise/Contusion Skin is not broken with possible discoloration, swelling, & pain.
Ecchymosis Irregularly formed hemorrhagic area of the skin. Color is blue-black changing to greenish
brown-yellow.
Petechiae Small purplish hemorrhagic spots on the skin or mucous membranes; may be singular or
multiple.
Puncture A wound deeper than it is wide and caused by a foreign object.
Wound Disruption of the skin.
Lesion Pathological in nature; usually not caused by trauma.
Bulls Eye Injury Patterned injury assuming the shape of the offending object; pale center with a
hypervascular or petechial surrounding area.
Patterned Shows specific repetition, patterned appearance or site of wounds.

Classification Use accepted terminology wherever possible (see chart below)

Site Record the anatomical position of the wound(s).
Size Measure the dimensions of the wound(s).
Shape Describe the shape of the wounds(s). (Linear, curved, irregular, crescent, patterned, circular)
Surrounds Note the condition of the surrounding or nearby tissues (swollen, bruised, ecchymotic,
petechial)
Color Observation of color is particularly relevant when documenting bruises, redness, burns.
Course Comment on the apparent direction of the force applied (e.g. in abrasions).
Contents Note the presence of any foreign material in the wound (e.g. sand, dirt, glass, fabric, hairs,
exudate color and consistency).
Age Do not estimate or document age of wound; it is impossible to accurately identify the age of
a wound. Comment on evidence of healing. Can document wound healing as evidenced by
approximated edges or bruises in various stages of healing as noted by varied coloration.
Scabs present or granulation present.
Borders The characteristics of the edges of the wound(s) (e.g. ragged laceration, clean, approximated
edges)
Depth Give an indication of the depth of the wound(s); this may have to be an estimate.
Tenderness/Pain Describe area or wound and level of tenderness and/or pain from 1-10 (10 highest)

Photographing Wounds
1. Ask permission to take photographs
2. Use a digital camera with a clean digital picture cartridge.
3. Take medium ranged photographs to get detail, as well as show perspective of where the wound is on
the body.
4. Take close up photos with an ABFO ruler to show scale and actual size of wounds.
5. Label all photos with the date, time, Volunteers name, part of the body and wound and PCMO initials.
6. Put labeled photos in an envelope in the medical record as clinical references for care.
 Managing Post-Traumatic Stress Reactions during the sexual assault exam (Sharkansky, 2011).
Despite providers best efforts, sometimes posttraumatic stress symptoms occur during an exam. If this
happens, dont panic. Use grounding techniques with the patient:
Speak in a calm, matter-of-fact voice and avoid any sudden movements.
Reassure the Volunteer that she is in a safe environment, and although she is having a reaction, she
will be okay.
Explain that you are examining her asking permission to continue the examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold washcloth for her
face.
If possible, go with her into a different room to provide a change of environment.

Perform a history-guided exam starting with the upper body first, then lower body providing a gown and cover
throughout the exam.

1. ARMS, TORSO, and LEGS EXAMINATION

Examine the Volunteer in this order (if indicated by the assault history). and describe any of the following specific
findings:
a) Hands and wrists: circular wounds or bruising, defense wounds, broken nails
b) Eyes and nose: petechial hemorrhaging
c) Torso: bruising (in different stages of healing?), lacerations, bite marks, other injuries. Inspect areas of the
body that would have been in contact with the surface on which the assault occurred.
d) Outer thighs and lower legs: circular wounds around ankles, bruising
e) Feet: heel abrasions from being dragged

2. HEAD,NECK, and ORAL EXAMINATION

Examine the face, head, hair, scalp, and neck for injury and foreign materials (if indicated by the assault history).
(Use Attachment E: Strangulation Addendum if a history of strangulation).

a) Mouth: inner aspects of lips, perioral region, buccal surfaces, gums, palate, and nares (frenulum and hard
palate often areas of trauma)
b) Ears: behind pinna for bruising, breached ear drums (from slapping/punching)
c) Neck: signs of bruising, patterns of bruising or injury around the neck
d) Scalp: areas of hair missing, lacerations, bruising, or other tender areas
e) Examine the oral cavity for injury and foreign materials

Collect swabs from the oral cavity for STI testing, if applicable

3. GENITAL EXAMINATION -FEMALES

Examine the inner thighs, external genitalia, and the perineal area for injury, foreign materials, and other
findings. Examine for Tears, Ecchymosis/bruising/contusion, Abrasions, Redness, Swelling (TEARS), bitemarks,
burns and pain. Check the appropriate boxes of any assault related findings.
Use a colposcope, if available, or employ other means of magnification.
Record size and appearance of injuries, foreign materials, and other findings using the diagrams, the legend,
and a consecutive numbering system. Note swelling and areas of tenderness and induration.

4. VAGINAL AND CERVICAL EXAMINATION

Examine the vagina and cervix for injury, foreign materials, foreign bodies (tampon, condom, etc.) and other
findings. Check the appropriate boxes if there are assault-related findings. Record findings using the legend
 and diagrams. Use a non-lubricated warm speculum moistened with water. Use a colposcope, if available, or
employ other means of magnification.
a) Mons pubis
b) Labia majora and minora
c) Clitoris
d) Urethra
e) Introitus and hymen (Examine by holding the labia at posterior edge between index finger and thumb and
gently pull outwards and downwards.) Describe areas of bruising and tears as on the face of a clock (e.g.
partial hymnal tear at 3 oclock)
f) Vaginal vestibule/navicular fossa: hymenal tears can extend to the vaginal vestibule /fossa navicularis
g) Posterior forchette: the most common site of injury showing bruising, tears, and abrasions
h) Cervix: gently introduce a speculum lubricated with sterile water. Check the cervix, vaginal walls, and posterior
fornix for trauma, bleeding, and signs of infection.

Special Considerations for Post-menopausal women

Post-menopausal women have decreased hormone levels that can cause reduced vaginal lubrication and friable
vaginal walls. This population is at increased risk for tears, injury and transmission of STIs and HIV. Ensure a well-
lubricated speculum is introduced into the vagina.

Collect swabs from the vagina/cervix for STI testing, if applicable

5. RECTOVAGINAL/BIMANUAL EXAM
Perform only if indicated from the history and exam findings to assess for abdominal trauma,rectovaginal tears,
bleeding, pregnancy, or infection.

6. ANAL AND RECTAL EXAMINATION-FEMALES

(Conduct exam if indicated by assault history.) Perform the exam while she lies on her back with thighs pulled
towards her abdomen and arms around the back of her legs).
Examine the buttocks, perianal skin, and the anal folds for injury, foreign materials, and other findings including
fissures, bruising, tears, bleeding, and/or fecal matter present on skin.
Check the appropriate boxes if there are assault-related findings using the legend and diagrams.

7. ANOSCOPIC EXAM-FEMALES
Conduct an anoscopic exam if rectal injury is suspected or if there is any sign of rectal bleeding.
Use an anoscope or anal speculum moistened with warm water or water soluble lubricant. Check the box if there
is rectal bleeding and describe findings.

Collect swabs from the anal/rectal cavity for STI testing, if applicable

8. GENITAL EXAMINATION-MALES
Examine the inner thighs, external genitalia, and the perineal area for injury, foreign materials, and other
findings. Examine for Tears, Ecchymosis/bruising/contusion, Abrasions, Redness, Swelling (TEARS), bitemarks,
burns and pain. Check the appropriate boxes of any assault related findings.
Use a colposcope, if available, or employ other means of magnification.
Record size and appearance of injuries, foreign materials, and other findings using the diagrams, the legend,
and a consecutive numbering system. Note swelling and areas of tenderness and induration.
a. Scrotum: swelling, bruising, bite marks, pain
b. Testicle: assess for testicular torsion as this an emergency and requires immediate surgical consultation
c. Penis (bitemarks, lacerations)
d. Periurethral tissue
e. Urethral meatus
f. Other considerations: Sexual history? Circumcised? Hematuria?

Collect swabs from the urethra for STI testing, if applicable

9. ANAL AND RECTAL EXAMINATION-MALES

 (Conduct exam if indicated by assault history by examining him while he lies on his back with thighs pulled towards
his abdomen and arms around the back of his legs.) Examine the buttocks, perianal skin, and the anal folds for
injury, foreign materials, and other findings. Check for fissures, bruising, tears, bleeding, fecal matter present on
skin.

Conduct an anoscopic exam if rectal injury is suspected or if there is any sign of rectal bleeding. Use an anoscope
or anal speculum moistened with warm water or water soluble lubricant. Check the box if there is rectal bleeding
and describe findings.

Collect swabs from the anal/rectal cavity for STI testing, if applicable

H. LABORATORY SAMPLES (SWABS)

Document the number of swabs, the area from which the sample (s) were taken, date collected, and any other
notes applicable.

I. SEROLOGY SAMPLES
Document which serology specimens collected.

J. RECORD PHOTO DOCUMENTATION

Document photographic methods used and areas which were photographed. Documentation must clearly link the
patient's identity to the specific photographs of injuries and/or findings, and if photos labeled and placed in
Volunteer Assault Record.

K. SUMMARIZE POSITIVE EXAM FINDINGS.

Inappropriate Clinical Findings Appropriate Clinical Findings Documentation

Documentation
Rape; Sexual Assault Incident
Victim Volunteer
Alleged No substitute and dont use. Alleged can be
misinterpreted to mean that the Volunteer
exaggerated or lied about the incident. e.g. alleged
rape, alleged assailant, etc.).
Intoxicated, drunk, under the Slurred speech, staggered gait, unable to focus
influence eyes, pupils dilated, etc.
Refused care, non-compliant, Unable to provide a specimen at this time
uncooperative
Refused parts of the exam, Unable to tolerate the vaginal exam.
Raped anally Anal trauma
Vaginal rape Vaginal trauma
Forced oral sex Oral trauma as evidenced by torn lower frenulum
and bruising on the hard palate
Blood Red liquid or thick substance found on clothing or
on skin. Can document as blood only if PCMO
sees the blood actively bleeding from a wound.
Seminal fluids White, crusty dried substance; sticky white
substance. Do not document as sperm, seminal
fluid or ejaculate.

L. EVIDENCE COLLECTED AND SUBMITTED TO CRIME LAB (Use SAK VEC100)

Document clothing, swabs, debris, etc. collected and stored as evidence using the SAK. Refer to TG 545 for
specific instructions.
M. TOXICOLOGY SAMPLES
Document any blood or urine samples collected.
N. REFERENCE SAMPLES from the VOLUNTEER
Document any blood, head hair, pubic hair, and/or saliva samples collected.
 O. ADDENDUM REPORTS USED DURING EXAM
Identify any other reports/forms used during the examination process.
P. PRINT NAMES OF EXAMINER and SUPPORT PERSON INVOLVED. Examiner to sign form and document any support
staff present during the exam.

Place the examination form into the medical record and a copy in an envelope inside the SAK. Do not place photos into
the SAK. They go in an envelope in the medical record.