SANE App Prototype 2

Forensic Exam Form Export Library

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SANE App Prototype 2

Forensic Exam Form Export Library

Resume an Existing Exam Form

Exam 1 Patient’s Last Name
Patient’s Number
Date Form Started
Date Last Edited

Exam 2 Patient’s Last Name

Patient’s Number
Date Form Started
Date Last Edited

Exam 3 Patient’s Last Name

Patient’s Number
Date Form Started
Date Last Edited

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SANE App Prototype 2

Forensic Exam Form Export Library

Basic Info
Patient’s name*:
Patient’s preferred name:
Patient’s date of birth*: 00/00/0000
Patient’s biological sex*: Male Female

Patient’s gender identity:

Patient’s pronouns:
Patient number*:
Kit number*:

Exam date/time*: 00/00/0000 24:00

Forensic examiner*:
Facility*:

Date/time of assault*: 00/00/0000 24:00

Hours post assault:
OSP SAFE kit collected*: Yes

Kit number:
Reporting*: Yes

Case number:
Medically screened per protocol*: Yes

(see medical record)

Collect oral swabs first, then the patient may have fluids. For reported/suspected
drug-facilitated sexual assaults, collect blood and urine samples as soon as possible. HIV
prophylaxis must be started within 72 hours of the assault.

Mandatory Reporting
Serious physical injury*: No

Injury from a deadly weapon*: Yes

Younger than 18 years of age*: No

65 years of age or older*: No

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SANE App Prototype 2

Forensic Exam Form Export Library

Injuries must be reported. A report of sexual assault is not mandated.

Disabled or mentally ill*: Yes

Agency reported to*:

Report made by*:
Date/time of report: 00/00/0000 24:00

Advocate called: No

Advocate present: No

Interpreter used: Yes

Name:
Language:

Others present during history:

Others present during exam:

Save & Continue

Jane Doe Patient 1234 Kit Number 1234

Save & Continue

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SANE App Prototype 2

Forensic Exam Form Export Library

Basic Info
Since
Injuries must be the Time ofA the
reported. Assault
report of sexual assault is not mandated.
Report of Incident

Disabled or mentally Pertinent/Recent

ill*: Health History Yes

Info Pertaining
Agency reported to*: to Assault

Report madeAssailant(s)
by*: Info

Date/time ofActs Described by the Patient

report: 00/00/0000 24:00
Strangulation Assessment

Advocate called: Drug-Facilitated Sexual Assault No

Assessment
Advocate present: No
Head-to-Toe Exam
Head & Neck Bodygram
Interpreter used: Yes
Full Body Bodygram
Name:
Hands & Feet Bodygram
Language:
Anogenital Exam & Bodygram
Evidence Collection
Others present during history:
HIV Risk Assessment
Others present during exam:
Treatment
Follow-Up & Referrals Save & Continue

Jane Doe Patient 1234 Kit Number 1234

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SANE App Prototype 2

Forensic Exam Form Export Library

Back
Head & Neck Bodygram Take a Photo
Physical Findings Noted: Yes

Fill out the Injury Log and take a photo, if applicable. Then, draw the injury. Each type of
injury is assigned a different color. Tap on any swatch in the key to draw with that color.
Press Done to finish drawing.

Injury Log
Injury #*: 1
Photo*: Yes

Forensic Photographer: No

Pain:
1-10
Description:

Enter text here.

Done
Key
Abrasion= Ecchymosis= Suction injury=
Bruising= Foreign body/debris= Tear=
Bite= Laceration= Tenderness=
Burn= Petechiae= Other injury=
Cut= Redness=
Contusion= Swelling=

Print Name Here Sign Here

Date Save & Continue

Jane Doe Patient 1234 Kit Number 1234

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SANE App Prototype 2

Cancel

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SANE App Prototype 2

Forensic Exam Form Export Library

Basic Info
Back
Head & Neck Bodygram:
Since the Time of the Assault
Take a Photo
Report of Incident
Physical Findings Noted: Yes

Pertinent/Recent Health History

Fill out the Injury LogInfo

and Pertaining to Assault
take a photo, if applicable. Then, draw the injury. Each type of
injury is assigned a different color. Tap on any swatch in the key to draw with that color.
Assailant(s) Info
Press Done to finish drawing.
Acts Described by the Patient
Injury Log Strangulation Assessment
Injury #*: Drug-Facilitated
1 Sexual Assault
Photo*: Assessment
Yes

Head-to-Toe Exam
Head & Neck Bodygram
Full Body Bodygram
Hands & Feet Bodygram
Forensic Photographer: No
Anogenital Exam & Bodygram
Pain:
Evidence1-10
Collection
Description:
HIV Risk Assessment
Enter text here.
Treatment
Follow-Up & Referrals

Done
Key
Abrasion= Ecchymosis= Suction injury=
Bruising= Foreign body/debris= Tear=
Bite= Laceration= Tenderness=
Burn= Petechiae= Other injury=
Cut= Redness=
Contusion= Swelling=

Print Name Here Sign Here

Date Save & Continue

Jane Doe Patient 1234 Kit Number 1234

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SANE App Prototype 2

Forensic Exam Form Export Library

Export
Recipients*: Crime Lab
Hospital
Law Enforcement

File type*: PDF

DOCX
JPG

Yes
Print:

Police Department Receipt of Evidence

This certifies that on April 1, 2019 at 12:00, evidence was:
Hand delivered to law enforcement
Locked in an evidence locker per facility protocol

Print name and title of the receiving agency Date

Signature of the receiving agency

Signature of the medical provider/nurse examiner Date

SANE number, if applicable

Preview

Export

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SANE App Prototype 2

Forensic Exam Form Export Library

Back
Preview

Export

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SANE App Prototype 2

Forensic Exam Form Export Library

Library
HIV Testing Algorithm (Quick Reference)

Oregon Medical Guidelines for Evaluation of Sexual Abuse in Children and Adolescents

Sexual Assault Medical Forensic Exam Form 2017

Sexual Assault Triage Algorithms

Adult
Child

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SANE App Prototype 2

Forensic Exam Form Export Library

Back
HIV Testing Algorithm (Quick Reference)

Print

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SANE App Prototype 2
No
Done
No

No
Healthy Heart Hospital
No

Town General Hospital No

No

Town Medical Center

Healthy Heart Hospital

She/Her/Hers

Done

She/Her/Hers

Him/He/Hiis

Them/They/Theirs

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