Final Data Collection Form

OMB NO: 1121-0324
EXP DATE: 05/31/2011

CLINICAL INDICATORS OF SEXUAL VIOLENCE IN CUSTODY

Date of Encounter:	Form Identification Number: TO BE COMPLETED BY CENTRAL REPORTER
ASSURANCE OF CONFIDENTIALITY: The information collected on this form shall be used for statistical and research purposes only. The Bureau of Justice Statistics assures confidentiality based on Title 42 USC § 3735 and 3789g.The Centers for Disease Control and Prevention assures that all information which would permit identification of any individual, a practice, or an establishment, will be held confidential, will be used for statistical purposes only by CDC staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m).
This is a passive surveillance system for clinical indicators of sexual violence in correctional facilities. Inmates should not be made aware of this project nor be interviewed to complete this form. Forms should be completed after an inmate leaves the exam area, when possible.	The REPORTER for each facility will be responsible for maintaining completed forms and serving as the point of contact for the facility, identifying duplicate forms, and reconciling any discrepancies before sending them to CDC. The REPORTER will be contacted monthly by CDC for a status update. Forms should be mailed to CDC on a monthly basis.
When does the form get filled out? If an inmate makes an allegation of sexual violence If a clinician has a suspicion of sexual violence If an inmate has any of the following conditions diagnosed as part of a medical examination: Unexplained rectal bleeding Rectal or anal tears or fissures Bruises, scratches, or abrasions on buttocks Genital bruising Nipple injuries Which inmates qualify? Male inmates ages 18 or older	Who can complete the form? Physicians Physician assistants (PA) Nurse practitioners (NP) Registered nurses (RN) Licensed practical nurses (LPN) Which incidents get recorded? Injuries that occurred during the current incarceration Allegations that are made about an incident that occurred during the current incarceration New onset of symptoms; forms do not need to be completed for chronic conditions unrelated to sexual violence

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 1121-0324.
PART A. INDICATORS OF SEXUAL VIOLENCE
Please respond to all items in A.1 and A.2.
Did the inmate make an allegation of sexual violence?  Yes Only record instances of these injuries when they are discovered as part of a routine medical examination. Do not examine every inmate for these injuries when they seek medical care. Record instances of these conditions even if there is no allegation of sexual violence.  No
D id the inmate have any of the following: Unexplained rectal bleeding?  Yes  No  Don’t know Rectal or anal tears or fissures?  Yes  No  Don’t know Bruises, scratches or abrasions on the buttocks?  Yes  No  Don’t know Genital bruising?  Yes  No  Don’t know Nipple injuries?  Yes  No  Don’t know
If you responded NO to A.1 and A.2, please respond to A.3.
Do you suspect there was an incident of sexual violence?  Yes  Please explain in COMMENTS on page 3  No
IF YOU ANSWERED YES TO ANY ITEM IN PART A, PLEASE COMPLETE PARTS B - F
PART B. INMATE DEMOGRAPHICS
Record current height and weight if measured during the examination or the most recent height and weight documented. Record race/Hispanic origin documented in the inmate’s medical record or by inmate self-report.
B.1 Age: years	B ft. inches .2 Height:			B pounds .3 Weight:
Race/Hispanic Origin: (Check one or more)  White  Asian  No Information Available  Black or African American  American Indian or Alaska Native  Hispanic or Latino  Native Hawaiian or Other Pacific Islander
PART C. GENERAL INJURY ASSESSMENT
Record if any of these injuries are identified as part of a routine medical examination. A separate exam for each of these injuries is not required.
Did the inmate have bruises or scratches to any of the following areas? (Mark all that apply)  Throat  Wrists  Ankles  Shoulders  Trunk  None of the above		Did the inmate have any of the following other injuries? (Mark all that apply)  Defensive injuries to the arms, hands, or fingernails  Broken bone(s)  Bite wound(s)  At least one tooth recently chipped or knocked out  Bruises or cuts in or near the mouth  None of the above
PART D. BEHAVIORAL OBSERVATIONS
This information is based on observations made during the medical examination; a separate examination by a mental health professional is not required.
High levels of anxiety. Does the inmate appear agitated or unusually upset during the examination? This may include fidgeting, crying, appearing to startle easily, trembling, or a report of having trouble sleeping.  Yes  No  Don’t know		Emotionally withdrawn. Does the inmate appear detached from others or in a daze, have difficulty concentrating, have difficulty attending to the examination, or appear lost in his own thoughts?  Yes  No  Don’t know
PART D. BEHAVIORAL OBSERVATIONS (cont.)
Extreme emotional reactions at the suggestion of sexual assault. If the inmate did not make an allegation of sexual violence, does he react with extreme anger or sadness at the suggestion of victimization? The clinician should not change his/her routine practice regarding discussion of sexual assault with inmates.  Yes  No  Don’t know  Inmate made an allegation of sexual violence		Story/report not matching the physical signs. If the inmate does not make an allegation of sexual violence (item A.1) but has one of the five indicators listed (item A.2) or you have a suspicion of sexual violence (item A.3), does his explanation of why he is injured seem implausible? Does he avoid discussing or thinking about the injury?  Story does not match physical signs / No explanation  Story matches physical signs  Don’t know  Inmate made an allegation of sexual violence
PART E. REFERRAL
Record if the treating clinician made a recommendation for any of the following items. A YES response should be made even if the inmate refuses the referral.
HIV/STD testing. Did the treating clinician recommend the inmate be tested for HIV, syphilis, gonorrhea, Chlamydia, hepatitis B, or another sexually transmitted disease as a follow up to this evaluation?  Yes  No
Referral to mental health. Did the treating clinician refer the inmate for a mental health examination?  Yes  No		Referral to another clinician. Did the treating clinician refer the inmate to be seen by another clinician?  Yes  No
Segregation, protective custody or transfer recommended. Did the treating clinician recommend to security staff that the inmate’s housing status be changed?  Yes  No		Incident report initiated. Did the treating clinician recommend that an incident report be initiated?  Yes  No
PART F. VISIT INFORMATION
Please respond to all items in Part F.
Level of training of treating clinician: (Mark ONE response)  Physician  Registered Nurse  Physician Assistant  Licensed Practical Nurse  Nurse Practitioner  Other ____________________			Method with which inmate came in contact with provider: (Mark ONE response)  Rounding  Routine medical appointment  Sick Call  Booking  Walk-in visit  Referral  Urgent care  Other ________________________  Emergency visit
Has the inmate been seen for the incident/injury listed in Part A in the past 30 days? Mark YES if the medical record indicates the inmate has been seen in the past 30 days for one or more conditions listed in Part A.  Yes  Date of most recent prior visit?  No
COMMENTS
Record any additional relevant information. Include any comments that would provide a more detailed portrayal of the circumstances surrounding the injuries/allegation.

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 1121-0324.