Clinical Indicators of Sexual Violence in Custody

Clinical Indicators of Sexual Violence in Custody

Attachment 3.

Data Collection Instrument

Clinical Indicators of Sexual Violence in Custody Surveillance Form							Date: _____/_____/ 20____
Part A. Indicators of sexual violence
Did the inmate make an allegation of sexual violence?  Yes  No	-OR-		Did the inmate have any of the following?
			 Rectal bleeding  Rectal or anal tears or fissures  Bruises, scratches, or abrasions on buttocks					 Genital bruising  Nipple injuries
If inmate made an allegation of sexual violence or any condition in Part A is identified, complete Parts B-E
Part B. Demographics
Age: _________(years) Height: _______(inches) Weight:_______(pounds)		Race (check all that apply):  White  Black or African American  Hispanic or Latino  Asian				 American Indian or Alaska Native  Native Hawaiian or Other Pacific Islander  No information available
Part C. General injury assessment
Did the inmate have any of the following injuries? (check all that apply)
 Bruises or scratches to the throat  Bruises or scratches to the wrists  Bruises or scratches to the ankles  Bruises or scratches to the shoulders  Bruises or scratches central on body				 Defensive injuries to the arms, hands or finger nails  Broken bone  Bite wound  Teeth chipped or knocked out recently  Bruises or cuts in or near the mouth
Part D. Mental health assessment
Check all that apply  High levels of anxiety  Post traumatic stress disorder				 Extreme emotional reactions at suggestion of sexual assault  Story/report not matching the physical signs
Part E. Follow-up
Check all that apply  HIV/STD testing  Mental health referral				 Segregation, protective custody, or transfer recommended  Incident report initiated
NOTICE: Public reporting for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 1121-XXXX.

Version: August 20, 2008