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OSCC Sexual Assault Clerking Note

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OSCC TEAM

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PERSONAL DETAILS

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Telephone

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Religion

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Occupation

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Monthly Income

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Education

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Marital History

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Number Of Children

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Male

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Female

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Date Of Arrival

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Time Of Examination

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Place Of Examination

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Police Report

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Accompanying Person(s)

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HISTORY OF THE INCIDENT

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Present Incident

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Date

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Time

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Location

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Place

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Town

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Street

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Circumstances That Led To The Incident (History)

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Is Force/Violence Was Used?

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Was Any Weapon Used By The Assailant?

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Did The Patient Put Up A Resistance?

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Was The Patient Restrained?

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Were Any Drugs Used?

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Was Any Alcohol Used?

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Other Relevant History

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Identity Of Assailant

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How Many Assailants?

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Is Assailant Known To Patient?

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DETAILS OF ACT

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Type Of Sexual Act

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Oral

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Vagina

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Anal

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What Was Used

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Finger

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Penis

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Other objects, specify

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Other objects, specify

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Condom Used

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Lubricants Used

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Did The Patient Experience Any Pain?

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Was There Any Bleeding?

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Other Symptoms

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History of events after the incident :

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Menstrual History

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Last Menstrual Period (LMP)

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Menarche

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Cycle

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Flow

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Interval

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Obstetric History

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Parity Index

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Gravida

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Para

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Abortion

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Date Of Last Child Birth

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Contraception

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Contraception

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Sexual History

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Past Experience Of Sexual Intercourse

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Previous Masturbation

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Medical History

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Medical History

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Immunization History (if a child)

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Last Toxoid/Att Date

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Surgical History

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Surgical History

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DEVELOPMENTAL HISTORY (IF A CHILD)

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SIGNATURE (DOCTOR PAEDIATRIC)

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PHYSICAL EXAMINATION

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VITAL SIGNS

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Vital Signs & Other Observations

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Pupils

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General Condition and Examination

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General Condition

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Behaviour

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Clothing

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General Build (Does It Correspond To Victim Age?)

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Gait

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Physical Examination Findings

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Secondary Sexual Characteristic

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Is There Any External Bruise/Abrasions/ Cuts/ Laceration ?

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Collection of Forensic Samples

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Collection of clothes

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Type of Clothes

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Total No. of Samples

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Samples Handed Over To Police Officer

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Samples Labelled & Packed by

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Name

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Designation

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Ic No

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Handed Over By

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Name

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Designation

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Ic No

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Received By

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Name

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Rank No

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Police Station

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TREATMENT AND AFTER CARE

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SIGNATURE (BY ETD DOCTOR)

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GYNAECOLOGICAL EXAMINATION

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Vulval Examination

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Vaginal Examination

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Vulva

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Record Tear

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Hymen Intact

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Intact

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Do not proceed for further vaginal examination

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Take smear from introitus

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Do rectal examination

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Torn

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Specimen Examination

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Bimanual Examination

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Cervix

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Cervix Position

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Cervix Size

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Cervix Status

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Cervix Contact Bleeding

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Cervix Tenderness

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Cervix Prolapse

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Cervix Comment

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Uterus

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Uterus Position

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Uterus Size

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Uterus Regularity

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Uterus Consistency

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Uterus Tenderness

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Uterus Mobility

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Uterus Comment

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Other

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Adnexae Examination

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Other Findings

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Examiners Finding

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Are there any body injuries?

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Can you specify the type of violence used?

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Are there any genital injuries?

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Do the genital injuries indicate?

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Sign of blunt object penetration of the vagina?

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Are there acute injuries?

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Is the history given consistent with examination findings?

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Are there any signs of abuse/torture?

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Does the patients physique correspond with his/her age?

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Are there any mental abnormalities?

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Is the patient mentally retarded?

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Are there any signs of intoxication?

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COLLECTION OF FORENSIC SAMPLES

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Collection of Forensic Samples

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Samples for Baseline UPT and STI

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Samples Handed Over To Police Officer

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As Above

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Samples Labelled & Packed by

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Name

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Designation

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Ic No

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Handed Over By

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Name

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Designation

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Ic No

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Received By

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Name

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Rank No

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Police Station

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Plan

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SIGNATURE (DOCTOR O&G)

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SODOMY

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Collection of Forensic Samples

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Total No. of Samples

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Samples Handed Over To Police Officer

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As Above

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Samples Labelled & Packed by

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Name

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Designation

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Ic No

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Handed Over By

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Name

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Designation

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Ic No

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Received By

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Name

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Rank No

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Police Station

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Plan

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Genito-Anal Examination

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Urethral Examination

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Rectal

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Inner Thigh

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External Genitalia

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Perineal Area

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Rectal Examination

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Anus / Anal Canal

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Anal Sphincter

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Muscle Tone

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Examiners Finding

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Are there any body injuries?

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Can you specify the type of violence used?

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Are there any genital injuries?

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Do the genital injuries indicate?

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Sign of blunt trauma?

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Are there acute injuries?

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Are there any anal injuries?

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Do the anal injuries indicate

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Sign of blunt object penetration into the anus?

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Are they acute injuries?

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Is the history given consistent with examination findings?

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Are there any signs of abuse/torture?

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Does the patients physique correspond with his/her age?

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Are there any mental abnormalities?

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Is the patient mentally retarded?

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Are there any signs of intoxication?

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SIGNATURE (DOCTOR SURGERY)

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PRELIMINARY REPORT

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As Above

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Police Report Number

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Police Station

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Police Officer Information

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Doctor(Who Gave The Report)

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Preliminary Report

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SIGNATURES

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