This project was supported by a grant awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings,

Transcription

1 This project was supported by a grant awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women.

2 Contents Membership 3 Executive Summary..5 Forensics Subcommittee Summary 6 Victim Services Subcommittee Summary..7 Law Enforcement Subcommittee Summary..8 Appendices...10 Appendix A: PERK (Physical Evidence Recovery Kit) Directions Appendix B: PERK (Physical Evidence Recovery Kit) Example Appendix C: Forensic Exam Model Facility Recommendations Summary Appendix D: SART Introduction Presentation Appendix F: Trauma Informed Sexual Assault Investigations Outline and Objectives 2

3 Membership Melissa Ashton, MSW Director, Victim Advocacy Program Florida State University Terri Augspurger, MSN, RN, CFN, SANE-A, SANE-P, AFN-B/C, DABFN, DABFE Clinical Forensic Nurse Examiner, Independent Instructor and Consultant Dr. Wade Barnes, MD Physician North Florida OB-GYN Associates Nicole Bishop, MSW Director, Justice Services and Victim Services & Rape Crisis Center Palm Beach County Victim Services and Rape Crisis Center David Brand Law Enforcement Coordinator Florida Sheriffs Association Hon. John L. Burns County Judge Charlotte County Justice Center Catherine Cothran, MS, F-ABC Senior Forensic Scientist Palm Beach County Sheriff s Office Sgt. William T. Crews Alachua County Sheriff s Office Jennifer Dritt, LCSW (LA) Executive Director Florida Council Against Sexual Violence Lorraine Elder, MSW Program Administrator Sexual Violence Prevention Program, Florida Department of Health Michelle English Executive Director Project Help 3

4 Grace Frances Director, Certification and Special Projects Florida Council Against Sexual Violence Captain Eric Garcia Criminal Investigations Division Miami-Dade Police Department Susan Garcia, MSW Special Victims Bureau Victim Advocate Miami-Dade Police Department Christina Harris Bureau Chief Florida Office of the Attorney General Advocacy and Grants Management LeAndra Higginbotham, Ph.D. Crime Laboratory Analyst Supervisor Toxicology Florida Department of Law Enforcement Concetta Holmes, LCSW, CA Victim Advocate Coordinator Sarasota County Sheriff s Office Sgt. Richard Mankewich Major Case/Sex Crimes Squad Orange County Sheriff s Office Tabitha McDonald Government Affairs Coordinator Florida Sheriffs Association Theresa Prichard, Esq. Director, Advocacy and Legal Assistance to Victims Florida Council Against Sexual Violence Marcella F. Scott Crime Laboratory Analyst Supervisor Biology Florida Department of Law Enforcement The Florida Statewide SART Advisory Committee is Coordinated by Micheala Denny, MS, Director of Program Development, Florida Council Against Sexual Violence. 4

5 Executive Summary The Statewide SART (Sexual Assault Response Team) Advisory Committee is a statewide group coordinated by Florida Council Against Sexual Violence and comprised of representatives from a broad range of disciplines whose work brings them into contact with rape survivors. The committee works to assess and improve Florida s response to survivors of sexual violence at the state and local level. In developing these recommendations and tools in this document, the members worked diligently to balance the needs of survivors with the complex requirements of the criminal justice system. The following recommendations and resources are intended to communicate best practices amongst local communities. The SART Advisory Committee s work in the year focused on three main areas: forensics, law enforcement and victim services. Each subcommittee tasked itself with providing insight and recommendations in pressing issues related to the response to sexual violence in Florida. While no community is compelled to adopt these recommendations, the Statewide SART Advisory Committee provides these recommendations based on extensive research and consultation with experts in the field. The underlying theme in all of the recommendations and resources is building the capacity of individual agencies and SARTs to address the diverse needs of sexual assault survivors. The Florida Council Against Sexual Violence commends the hard work and dedication of the SART Advisory Committee members. On their behalf we encourage policy makers and community leaders to enact these recommendations and share these resources in order to provide victims of sexual violence the response they deserve and the services they need to overcome the trauma of rape. Florida Council Against Sexual Violence 1820 E. Park Avenue, Suite 100 Tallahassee, FL

6 Forensics Subcommittee Recommendations The Forensics Subcommittee s worked during the year to further identify best practice recommendations for the State of Florida agencies regarding the collection, storage, and testing of evidence gathered from survivors of sexual assault. The subcommittee produced three main recommendations: physical evidence recovery kit (PERK) directions for suspects, a sample of what a PERK should contain, and forensic exam model facility recommendations (See Appendices A, B &C). In addition to these recommendations, the forensics subcommittee members continue to conduct research and evaluation for emerging practices in the field. Members of the FCASV Statewide SART Forensics Subcommittee include: Terri Augspurger, Forensic Nurse Examiner, Independent Instructor and Consultant Dr. Wade Barnes, North Florida OB-GYN Associates Catherine Cothran, Senior Forensic Scientist, Forensic Biology Unit, Palm Beach County Sheriff s Office Christina Harris, Bureau Chief, General Advocacy and Grants Management, Office of the Attorney General LeAndra Higginbotham, Crime Laboratory Analyst Supervisor, Toxicology, Florida Department of Law Enforcement Concetta Holmes, Victim Advocate Coordinator, Sarasota County Sheriff s Office Sergeant Richard Mankewich, Major Case/Sex Crimes Squad, Orange County Sheriff s Office Marcella Scott, Crime Laboratory Analyst Supervisor, Biology, Florida Department of Law Enforcement 6

7 Victim Services Subcommittee Recommendations The Victim Services Subcommittee focused on expanding resources, sample documents and suggested activities for individual SARTs. These recommendations have been integrated into the updated Florida SART Toolkit. In particular, the Victim Services Subcommittee developed a SART development slide presentation that can be used by individuals interested in initiating a SART in their community (see Appendix D). Members drew upon their experiences in their own communities as well as on input from state and national resources to develop more hands-on approaches to SART development and retention. The Victim Services Subcommittee also served as a sounding board for some of the legislative initiatives that FCASV took on in the spring. Members of the Statewide SART Victim Services Subcommittee include: Melissa Ashton, Director, Florida State University Victim Advocacy Program Nicole Bishop, Director, Palm Beach County Victim Services & Rape Crisis Center Lorraine Elder, Program Administrator, Sexual Violence Prevention Program, Florida Department of Health Michelle English, Executive Director, Project HELP Susan Garcia, Special Victims Bureau Victim Advocate, Miami-Dade Police Department Concetta Holmes, Victim Advocate Coordinator, Sarasota County Sheriff s Office Theresa Prichard, Director of Advocacy and Legal Assistance to Victims, Florida Council Against Sexual Violence Micheala Denny, Director of Program Development, Florida Council Against Sexual Violence 7

8 Law Enforcement Subcommittee Recommendations The Law Enforcement Subcommittee developed an eight-hour in-person training on trauma informed sexual assault investigations for law enforcement officers. Trauma informed investigations have gained traction across the country as law enforcement agencies are realizing the benefits of working with survivors of sexual violence in a different way. The training explains how trauma affects the brain, influencing victims reactions and memory during and after the assault. During trauma the rational part of the brain is shut down or greatly impaired, and the more primitive, survival centered areas take over. The brain focuses on and records memories of the details it deems most central to its survival rather than what it considers peripheral details, such as timeframes, sequence of events, or even an attacker s obvious physical traits. Memories are often linked to sensory information the brain took in during the assault (smells, sounds, tastes). In addition to affecting memories, when the rational brain is impaired during trauma, victims may do things that seem counterintuitive, like not crying out for help during the assault or walking past a police station after the attack without stopping to report it. Building on this information about the brain and trauma, law enforcement officers learn how to use the Forensic Experiential Trauma Interview (FETI). FETI was developed to uncover what victims are able to remember using questions that trigger recollections related to sensory memories recorded during the assault. The training also teaches how detectives can use this psychophysiological evidence to effectively investigate a case and corroborate the victim s account. Trauma informed investigations using the FETI technique are a new development for most law enforcement agencies in the country, Florida included. The Law Enforcement Training Subcommittee engaged the Orange County Sheriff s Office and Jacksonville Sheriff s Office as pilot sites to learn and implement FETI and trauma informed investigative principles. Sgt. Richard Mankewich of Orange County Sheriff s Office is the lead trainer, teaching the material informed by his experience supervising a team of detectives using the techniques. Grace Frances, FCASV Director of Certification and Special Projects, presents on the neurobiology of trauma and the reality of sexual assault for survivors. The first two trainings were hosted by the Palm Beach County Sheriff s Office and the Hillsborough County Sheriff s Office. Included in these recommendations are the outline and objectives for the trainings as well as a list of resources for additional training and information on topics related to trauma informed investigations. 8

9 Members of the Statewide SART Law Enforcement Subcommittee include: Sergeant Richard Mankewich, Major Case/Sex Crimes Squad, Orange County Sheriff s Office David Brand, Law Enforcement Coordinator, Florida Sheriff s Association Sergeant William Crews, Alachua County Sheriff s Office Grace Frances, Director of Certification and Special Projects, Florida Council Against Sexual Violence Captain Eric Garcia, Criminal Investigations Division Miami-Dade Police Department Concetta Holmes, Victim Advocate Coordinator, Sarasota County Sheriff s Office Tabitha McDonald, Government Affairs Coordinator, Florida Sheriff s Association Marcella Scott, Crime Laboratory Analyst Supervisor - Biology Section, Florida Department of Law Enforcement Consulting Members for the Law Enforcement Subcommittee include: Mariann D Arcangelis, Distance Learning and Publishing, Florida Department of Law Enforcement Assistant Chief Chris Butler, Crimes Against Persons, Jacksonville Sheriff s Office 9

10 Appendices 10

11 Suspect Evidence Collection Appendix A PERK Directions (Physical Evidence Recovery Kit) When a sexual assault occurs, the most common DNA evidence collections are from the victim. Often the collection of body swabs and clothing from a suspect are overlooked and valuable evidence may be lost. The following is a list of steps for the collection of the physical evidence recovery kit (PERK) from the most common body areas of a suspect of sexual assault. Physical evidence can be collected by law enforcement officers, criminalistics/forensics personnel or medical professionals. If a non-medical professional performs the collection there must be no internal swabs collected; mouth swabs are the only exception. Training for collection techniques by medical professionals or forensic personnel is recommended. NOTE: STERILE GLOVES AND FACE MASK SHOULD BE WORN BY LAW ENFORCEMENT DURING COLLECTION OF EVIDENCE All swabs collected during the examination can be immediately placed into the designated swab box after collection and then into a labeled envelope. Swab boxes are ventilated for drying. If swab boxes are not available place them tip down into the end wrapper from the original cotton swabs package and then into an envelope. Label the envelope with suspect s name, DOB, date, case identifier, specimen collection location, potential source of the specimen per case history and seal. STEP 1: RIGHT HAND SWABS AND FINGERNAIL SCRAPING COLLECTION Place collection sheet of paper on a flat surface. Hold the subject s hand over the paper. Using a wooden or plastic scraping stick, scrape under each nail, allowing any debris to fall onto the paper. Place scraping stick in the center of the paper and fold so as to retain the pick and any evidence collected. Place the folded paper into an envelope and label RIGHT HAND SWABS AND FINGERNAIL SCRAPING. Include the suspect s name, DOB, date, case identifier/number, and collector s signature. Using two swabs simultaneously add one or two drops of water to each cotton tip and swab the hand and fingers. Place swabs in swab box or envelop and put into the envelope label RIGHT HAND SWABS AND FINGERNAIL SCRAPING and seal envelope using labels or tape. Do not wet seal envelopes (this applies to all envelopes in kit). A proper seal is made using evidence tape with your initials at the junction of the tape and paper, ensuring that it covers both the tape and bag. 11

12 STEP 2: LEFT HAND SWABS AND FINGERNAIL SCRAPING COLLECTION Repeat procedure above for left hand. STEP 3: EXTERNAL MOUTH SWABS Using two swabs simultaneously, add one or two drops of water to each cotton tip and swab the outer mouth area; include lips and surrounding areas. Roll swabs to ensure that the entire cotton tip makes contact with indicated area. Place swabs in swab box or envelope and put into an envelope labeled EXTERNAL MOUTH SWABS and seal envelope. Include the suspect s name, DOB, date, case identifier/number, and collector s signature. STEP 4: BUCCAL SWABS Using two swabs simultaneously, swab the inside cheeks of the mouth. Place swabs in swab box or envelope and put into an envelope labeled BUCCAL SWABS and seal envelope. Include the suspect s name, DOB, date, case identifier/number, and collector s signature. STEP 5: CLOTHING Collect and place clothing into individual paper bags and seal. Label with description, name of suspect, DOB, date, case identifier, and collector s initials. STEP 6: PUBIC HAIR COMBINGS Unfold towel and hold under groin area. Comb the pubic hair in downward strokes to allow any debris or loose hairs to fall onto the paper towel. This can be done sitting or standing. If sitting, place towel on chair prior to the individual sitting. Place the comb in the center of the towel and fold so as to retain the comb and any evidence collected. Place the towel into an envelope labeled PUBIC HAIR COMBINGS and seal envelope. Include the suspect s name, DOB, date, case identifier/number, and collector s signature. STEP 7: PENILE SWABS Using two swabs, simultaneously add one or two drops of water to each cotton tip and swab the penis. Be sure to thoroughly swab cracks and juncture of structures. If uncircumcised, swab external surface area, ask the individual to retract foreskin and swab under. Instruct suspect to replace foreskin. If the individual does not consent do NOT attempt to retract. Retraction of the foreskin must only be done by the individual or a medical professional. Place swabs in swab box or envelope then place in envelope labeled PENILE SWABS and seal envelope. Include the suspect s name, DOB, date, case identifier/number, and collector s initials. 12

13 STEP 8: DEBRIS/OTHER COLLECTION Use this envelope to collect additional debris or samples if necessary such as bite marks, scratches and additional internal mouth swabs. SWABBING TECHNIQUE FOR MISCELLANEOUS AREAS OF EVIDENCE COLLECTION Dry Areas: Slightly moisten two (2) sterile cotton swabs with sterile water. While swabbing, rotate swab ensuring that all surfaces of the cotton tip make contact. Additional moisture may be needed to completely collect specimen. Pressure should be firm but not vigorous. Wet Areas: Utilize at least two (2) sterile cotton swabs (or more if swabs become saturated) for collection of moist secretions. While swabbing, rotate swab ensuring that all surfaces of the cotton tip make contact. Pre-moistening is not necessary for already moist/wet areas. FINAL INSTRUCTIONS Collect and place clothing in paper bags provided and submit separately to the PERK. Fill out all information requested on the parent PERK envelope and affix biohazard seal where indicated. Return envelopes, STEPS 1 through 7, to the parent PERK envelope. Initial and affix red police evidence seal to the parent PERK envelope. 13

14 Appendix B PERK Sample Kit Outer most envelope Kit Contains: Envelopes 1 thru 7 (see below) (2) outer clothing bags (1) underwear bag (1) 3ml vial of sterile water (1) face mask Instruction page with consent form on back and evidence tape 14

15 Step 1 and 2 Right and Left Hands Envelopes Contain: 2 swabs and 1 swab box for swabbing the hand Wooden pick and folded paper for fingernail scrapings Step 3 Envelope Contains: 2 swabs and 1 swab box for swabbing the outside lip and mouth area Step 4 Envelope Contains: 2 swabs and 1 swab box (may be used as a reference sample) 15

16 Step 5 Envelope Contains: Comb Paper towel Step 6 Envelope contains: 2 swabs and 1 swab box Step 7 Envelope contains: 2 swabs and 1 swab box for miscellaneous swabbing 1 folded paper for debris collection 16

17 2 Outer Clothing Bags 1 Underwear Bag 17

18 CONSENT TO SEARCH (PHYSICAL EVIDENCE RECOVERY KIT) I,, of my own free will, hereby consent to the search of my person and clothing for the collection of trace evidence for any analysis or comparison that the investigating agency deems necessary. I understand that I have the right to refuse consent to search prior to or during the search. I further understand that I may consent to the collection of all, some, or none of the listed items. By placing my initials next to each item, I hereby consent to the collection of the listed item: Step Description Initials 1 Right hand: swabs and fingernail scrapings 2 Left hand: swabs and fingernail scrapings 3 External mouth swabs 4 Buccal swabs 5 Pubic hair combing 6 Penile swabs 7 Debris/other collection Clothing - Outer Clothing Clothing - Underwear This consent is entered into with the full understanding that the results of any analysis may be used against me in a court of law and hereby affirm that I am submitting this consent of my own free will. I have not been promised anything in exchange for my consent nor have I been threatened or coerced in any manner. Signed: Date: Print Name: Witness: Date: Print Name: Witness: Date: Print Name: 18

19 Appendix C Model Forensic Exam Facility Recommendations The model forensic facility will be located within a healthcare agency (i.e. hospital-based program) that provides designated examiners for the purpose of the medical forensic examinations. The ideal examination area should be designated for the purpose of the medical forensic examination of patients reporting sexual assault and should be separate from the Emergency Department but have access to the resources of the department. Facilities used for medical forensic examinations should consist of: An examination room An interview area that is separate from the exam room A waiting area to accommodate law enforcement, family members, etc. A bathroom with shower facilities for the patient Examinations are also currently being provided in free-standing forensic examination facilities. These facilities have additional considerations given they are not within a healthcare agency. Below are recommendations for both hospital-based and free-standing programs. Hospital-Based Forensic Examination Program Logistical/Practice Considerations For Exam Facility 1. Recommended Protocols Sexual Assault Response Team Protocol establishing procedure, call out, response time, etc. Protocol should include provisions for patient triage in exam room and private designated path to exam room. Drug Facilitated Sexual Assault protocol Care of pregnant patient reporting sexual assault Medication administration protocols Evidence collection, preservation and packaging protocols including storage and chain of custody for non-report cases Emancipated minor protocol Incapacitated patient consent protocol Strangulation policy Referral protocols/policies Transport of patient as contingency for times of increased volume/diversion Conflict of interest for examiner 19

20 2. Equipment safety/servicing/calibration Establish procedures for annual/semi-annual biomedical evaluations of any equipment that is used for patient care, i.e. colposcopes, automatic BP machines, etc. 3. Examination The examination process will be in accordance with Adult and Child Sexual Assault Protocols: Initial Forensic Physical Examination and specific agency protocols. The response should minimize the wait for examination and incorporate best practice to provide optimal care to the patient and preserve/protect potential evidence. Evidence should be packaged at site of collection and transferred immediately to the investigating law enforcement agency. In the event that law enforcement is not available, temporary provisions at the facility should be made to maintain evidence integrity and preservation until such time that law enforcement can retrieve. 4. Cleaning of Examination Room Cleaning of room should follow agency protocols to decrease contamination in regards to pathogens (approved cleaning solutions, etc.). Cleaning to decrease cross contamination in regards to DNA, should include the same cleaning solutions and also involve vigorous wiping/rubbing (to facilitate removal of DNA sources). All potential areas of contact should be cleaned (i.e. exam table, door knobs, chairs, etc.). Swab dryers. Electric swab dryers are not recommended due to high probability of cross contamination. If such dryers are utilized, stringent cleaning protocols should be in place between exams. Only dryers from forensic companies that provide cool passive air circulation should be considered. 5. Examiner Training Regardless of degree, any healthcare practitioner who will be conducting examinations should receive training in conducting medical forensic examinations. Content of the training should address the content outlined and according to the educational guidelines of the Sexual Assault Nurse Examiner Education Guidelines (IAFN 2007), National Protocol for Sexual Assault Medical Forensic Examinations: Adult/Adolescent (DOJ 2013), National Training Standards for Sexual Assault Medical Forensic Examiners (DOJ 2006) and the Guidelines for Medico-Legal Care for Victims of Sexual Violence (WHO 2003). It is recommended that at the minimum examiners not seeking certification obtain the same training so as to be deemed board-eligible. Ideally, examiners should obtain certification within 3 years of independent practice. 20

21 Training specifications: 40 hour classroom and didactic baseline instruction (verify that curriculum adheres to guidelines) Subsequent clinical instruction and verification of competency validation should be completed in order to build clinical competency following the 40-hour course Competency validation should be achieved utilizing any of the following approaches: o Clinical experience with patients following sexual assault while precepted by a physician, advanced practice nurse, or forensically experienced/certified registered nurse (SANE-A), adhering to the clinical content specified until competency is achieved. o Simulated patient experience utilizing live models while precepted by a physician, advanced practice nurse, or forensically experienced/certified registered nurse (SANE-A), adhering to the clinical content specified until competency is achieved. o Simulated patient experiences utilizing medical simulation models while precepted by a physician, advanced practice nurse, or forensically experienced/certified registered nurse (SANE-A), adhering to the clinical content specified until competency is achieved. Agency specific annual requirements for continuing education and competency should be in place and provided for examiners to ensure practice remains current. 6. Clinical Coordinator Qualifications: The clinical coordinator will be one of the following: An active unrestricted licensed RN with SANE certification and a minimum of 2 years active practice in forensic examinations, with proof of validation of competency. An active unrestricted advanced practice RN (APRN) with SANE certification (or other forensic certification). An active unrestricted advanced practice RN (APRN) with a minimum of 2 years active practice in forensics and proof of competency validation. 7. Peer Review/Chart Audit for Quality Assurance Peer review and chart audit to maintain quality should be conducted on a frequent basis (i.e. monthly). Examiners should be provided feedback from chart reviews and be given the opportunity to also participate and provide feedback in the peer review process. 8. SART Multi-Disciplinary Team Members Advocacy (victim, law enforcement, judicial, etc.) Examiner 21

22 Law Enforcement Agencies Laboratory Analyst Child Protective Team Prosecutor Hospital and Healthcare facility representatives (Planned Parenthood, etc.) Counselor Universities Military Department of Health 9. Reimbursement Procedures from Office of Attorney General (OAG) The Bureau of Victim Compensation pays for medical expenses connected with the initial forensic physical examination of a victim of sexual battery or a lewd or lascivious offence. Payments re awarded regardless of whether the victim is covered by health of disability insurance. Payments are not contingent on the victim s participation in the criminal justice system or cooperation with law enforcement. Submission of the claim form and invoice must be submitted to the department within 120 days of the exam for reimbursement, and the payment may not exceed $500 with respect to any violation. The victim must not be billed directly or indirectly for expenses associated with the examinations. It is recommended that service providers complete the following prior to performing the examination: Contact the department to schedule a meeting with a regional specialist to receive invoicing guidance Register as an active participating vendor and submit a Substitute Form W9 to the Department of Financial Services. For additional instructions and training about how to register for the Statewide Vendor File, visit FLVendor.MyFloridaCFO.com. To modify or update your vendor information, or to request activation or W9 verification, contact the Vendor Management Section at (850) , or FLW9@MyFloridaCFO.com The claim form must be witnessed (signed and dated) by another individual employed with the facility as verification that examination was performed. 22

23 To submit the claim by mail use the following address: Bureau of Victim Compensation PL-01 The Capitol Tallahassee, FL To submit the claim by fax use one of the following two numbers: (850) or (850) To submit the claim by to: All claim forms must be accompanied by an itemized invoice which includes the following: Name of the facility used for the examination Date of the examination Patient s name Examination diagnostic code V71.5 and one or more of the following procedure codes: o Certified of board-eligible healthcare examiner s office or other outpatient services o Emergency department services o Use of medical facility for the collection of forensic evidence o Venipuncture for the collection of blood samples o Laboratory tests for baseline sexually transmitted disease and pregnancy o Forensic evidence collection kit To check on progress of invoices for reimbursement visit 23

24 Free Standing Forensic Examination Program Logistical/Practice Considerations For Exam Facility 1. Health Code Compliance Meet with local representative of Health Department to apply for bio-hazardous generator permit Devise plan for bio-hazardous waste and have manual available for inspection (see DOH website section on bio-hazardous waste) Devise large spill plan/response Designate location of bio-hazardous holding Devise pick up schedule, payment for biohazardous transport company, etc. Specification of laundering of re-usable linens, etc. (towels, sheets, bath floor mats, etc.) of contaminated items 2. OSHA Guidelines for Facilities Providing Healthcare Related Services OSHA provides free on-site consultation for small businesses to assist with compliance and identify any hazards (separate from enforcement activities and will not result in penalties). Visit for more information. Bloodborne Pathogens Standard (29 CFR ) This is the most frequently requested and referenced OSHA standard affecting medical and dental offices. Some basic requirements of the OSHA Bloodborne Pathogens standard include: A written exposure control plan, to be updated annually Use of universal precautions Consideration, implementation, and use of safer, engineered needles and sharps Use of engineering and work practice controls and appropriate personal protective equipment (gloves, face and eye protection, gowns) Hepatitis B vaccine provided to exposed employees at no cost Medical follow-up in the event of an exposure incident Use of labels or color-coding for items such as sharps disposal boxes and containers for regulated waste, contaminated laundry, and certain specimens Employee training Proper containment of all regulated waste Refer to Guide To Infection Prevention For Outpatient Settings: Minimum Expectations for Safe Care, published by the CDC in This guideline and 24

25 others are available at 3. Examiners Employees or contract - consult labor laws regarding contract versus employee. Considerations for safety of examiners, i.e. facility safety. Plan/protocol for response to exposure to HIV, TB, Hepatitis, etc., and provisions for prophylaxis and medical follow-up and testing for examiners Malpractice insurance if examiners are contractual Agency insurance for patients seen at facility 4. Response to emergent situation/decompensating patient Protocols for triaging patients which patients to free standing clinic versus which patients should be seen in ED Intermittent treatment response until arrival of rescue - Ambu bags - Oxygen - AED Protocol for transportation of unstable patient or patient in need of immediate assessment i.e. rescue. Strongly recommend liability waiver if patient refuses transport by rescue. 5. Medication Administration Consult board regulations and regulations of dispensing practitioner permit (even if meds are complimentary), prescriptive authority regulations (i.e. HCP patient relationship and examination stipulations), and labeling/storage regulations for controlled substances. Follow-up needs to be arranged for patients receiving prophylaxis. 6. Recommended Protocols Triage protocol Sexual Assault Response Team Protocol establishing procedure, call out, response time, etc. DFSA protocol Care of pregnant patient reporting sexual assault Medication administration protocols Evidence collection, preservation and packaging protocols including storage and chain of custody for non-report cases Emancipated minor protocol Incapacitated patient consent protocol Strangulation policy 25

26 Referral protocols/policies Transport of patient protocol Conflict of interest for examiner 7. Equipment safety/servicing/calibration Establish procedures for annual/semi-annual biomedical evaluations of any equipment that is used for patient care, i.e. colposcopes, automatic BP machines, etc. 8. Examination The examination process will be in accordance with the updated Protocol for sexual assault examinations (see resources) and specific agency protocols. The response should minimize the wait for examination and incorporate best practice to provide optimal care to the patient and preserve/protect potential evidence. Evidence should be packaged at site of collection and transferred immediately to the investigating law enforcement agency. In the event that law enforcement is not available, temporary provisions at the facility should be made to maintain evidence integrity and preservation until such time that law enforcement can retrieve. 9. Cleaning of Examination Room Cleaning of room should follow agency protocols to decrease contamination in regards to pathogens (approved cleaning solutions, etc.) Cleaning to decrease cross contamination in regards to DNA, should include the same cleaning solutions and also involve vigorous wiping/rubbing (to facilitate removal of DNA sources). All potential areas of contact should be cleaned (i.e. exam table, door knobs, chairs, etc.) Swab dryers- electric swab dryers are not recommended due to high probability of cross contamination. If such dryers are utilized, stringent cleaning protocols should be in place between exams. Only dryers from forensic companies should be considered that provide cool passive air circulation 10. Examiner Training Regardless of degree, any healthcare practitioner who will be conducting examinations should receive training in conducting medical forensic examinations. Content of the training should address the content outlined and according to the educational guidelines of the Sexual Assault Nurse Examiner Education Guidelines (IAFN 2007), National Protocol for Sexual Assault Medical Forensic Examinations: Adult/Adolescent (DOJ 2013), National Training Standards for Sexual Assault Medical Forensic Examiners (DOJ 2006) and the Guidelines for Medico-legal Care 26

27 for Victims of Sexual Violence (WHO 2003). It is recommended that at the minimum, examiners not seeking certification obtain the same training so as to be deemed board-eligible. Ideally, examiners should obtain certification within 3 years of independent practice. Training specifications: 40 hour classroom and didactic baseline instruction (verify that curriculum adheres to guidelines) Subsequent clinical instruction and verification of competency validation should be completed in order to build clinical competency following the 40-hour course Competency validation should be achieved utilizing any of the following approaches: o Clinical experience with patients following sexual assault while precepted by a physician, advanced practice nurse, or forensically experienced/certified registered nurse (SANE-A), adhering to the clinical content specified until competency is achieved o Simulated patient experience utilizing live models while precepted by a physician, advanced practice nurse, or forensically experienced/certified registered nurse (SANE-A), adhering to the clinical content specified until competency is achieved o Simulated patient experiences utilizing medical simulation models while precepted by a physician, advanced practice nurse, or forensically experienced/certified registered nurse (SANE-A), adhering to the clinical content specified until competency is achieved Agency specific annual requirements for continuing education and competency should be in place and provided for examiners to ensure practice remains current. 11. Clinical Coordinator Qualifications: The clinical coordinator will be one of the following: An active unrestricted licensed RN with SANE certification and a minimum of 2 years active practice in forensic examinations, with proof of validation of competency An active unrestricted advanced practice RN (APRN) with SANE certification (or other forensic certification) An active unrestricted advanced practice RN (APRN) with a minimum of 2 years active practice in forensics and proof of competency validation 12. Peer Review/Chart Audit for Quality Assurance Peer review and chart audit to maintain quality should be conducted on a frequent basis (i.e. monthly). Examiners should be provided feedback from chart reviews and 27

28 be provided the opportunity to also participate and provide feedback in the peer review. 13. SART Multi-Disciplinary Team Members Advocacy (victim, law enforcement, judicial, etc.) Examiner Law enforcement agencies Laboratory analyst Child Protective Team Prosecutor Hospital and healthcare facility representatives (Planned Parenthood, etc.) Counselor Universities Military Department of Health 14. Reimbursement Procedures from Office of Attorney General (OAG) The Bureau of Victim Compensation pays for medical expenses connected with the initial forensic physical examination of a victim of sexual battery or a lewd or lascivious offence. Payments re awarded regardless of whether the victim is covered by health of disability insurance. Payments are not contingent on the victim s participation in the criminal justice system or cooperation with law enforcement. Submission of the claim form and invoice must be submitted to the department within 120 days of the exam for reimbursement, and the payment may not exceed $500 with respect to any violation. The victim must not be billed directly or indirectly for expenses associated with the examinations. It is recommended that service providers complete the following prior to performing the examination: Contact the department to schedule a meeting with a regional specialist to receive invoicing guidance Register as an active participating vendor and submit a Substitute Form W9 to the Department of Financial Services. For additional instructions and training about how to register for the Statewide Vendor File, visit FLVendor.MyFloridaCFO.com. To modify or update your vendor information, or to request activation or W9 verification, contact the Vendor Management Section at (850) , or FLW9@MyFloridaCFO.com 28

29 The claim form must be witnessed (signed and dated) by another individual employed with the facility as verification that examination was performed. To submit the claim by mail use the following address: Bureau of Victim Compensation PL-01 The Capitol Tallahassee, FL To submit the claim by fax use one of the following two numbers: (850) or (850) To submit the claim by to: All claim forms must be accompanied by an itemized invoice which includes the following: Name of the facility used for the examination Date of the examination Patient s name Examination diagnostic code V71.5 and one or more of the following procedure codes: o Certified of board-eligible healthcare examiner s office or other outpatient services o Emergency department services o Use of medical facility for the collection of forensic evidence o Venipuncture for the collection of blood samples o Laboratory tests for baseline sexually transmitted disease and pregnancy o Forensic evidence collection kit To check on progress of invoices for reimbursement visit 29

30 Hospital-Based and Free-Standing Forensic Exam Supplies Exam Room Equipment/Supplies Exam table with adjustable stirrups (GYN exam table) Paper for covering table Beside table/procedure table (rolling) Rolling stool Overhead light Lift top trashcan (regular trash) Biohazard trashcan Sharps disposal Camera with SD cards; extra batteries/charger; flash/ring flash; macro lens CD burner OR computer with password protection and restricted access for downloading of photographs; CDs and covers ABFO ruler (right angle ruler) Straight ruler and flexible tape measure Case cards (for photographs establish chain-ofcustody) Dry erase markers Sharpie markers Evidence tape Evidence bags of variable sizes (paper) Sticky notes Swab holder for drying swabs Locking file cabinet to house charts (limited access by authorized personnel only - to maintain HIPPA and confidentiality) Locking refrigerator for temporary storage of liquid evidence (blood, urine) with chain-of-custody form Protocol/policy manual with applicable documents Blank charts with examination paperwork medical, forensic, photo log, consent form, etc. hardcopy or electronic Alternate light source (ALS) Extra body diagrams Sexual assault forensic exam kits Drug facilitated sexual assault kits Medical Instruments/Supplies BP cuffs (small, medium, large) and sphygmomanometer Otoscope/Ophthalmoscope (assessment of eyes, tympanic membrane in strangulation, etc.) Thermometer (disposable or w/disposable covers) Pulse ox (finger) Stethoscope Speculums individually wrapped Sizes: small, medium, large Speculum light (fits into speculum handle) Toluidine blue KY jelly individual packs Sterile water bullets Sterile 4x4 s (pre & post urination wipe) Sterile urine cups Urine pregnancy tests Sterile swabs Disposable tweezers Scissors Gloves Face masks Other Supplies Examination gowns Various sized clothing for patients Flip flops/replacement shoes Shampoo, body soap, combs (if showering is an option) Towels Mats for bathroom floor Eye protection 30

31 Appendix D SART Introduction Presentation The following slides and notes are available to any user who would like to propose a SART in their community. It is recommended that individuals use this information as a jumping off point for their presentation. The slides have been left intentionally plain so that the presentation can be customized to suit the needs of the presenter and audience. Most of the slides include notes that detail activities, resources and other information that will be useful to new SART teams. For more information on how to build and sustain SART teams please visit 31

32 32

33 Use this time to welcome participants and allow them to introduce themselves. If you like, use a flipchart to track answers. Options for questions to ask participants to answer include: please tell us your name, the agency you work for and: 1. One way that you work to serve survivors of sexual violence 2. One thing related to sexual violence that you think the community needs to hear more about 3. One challenge to working with survivors of sexual violence that you encounter 4. One way that working with other agencies helps you to get your job done 33

34 Use this slide to introduce how sexual violence impacts the community you serve. This is a good time to add facts and statistics that are specific to your area. This can include crime report data, anecdotes about cases in the news, information about why sexual violence often goes unreported, etc. Emphasize the role that a SART can have in helping the community cope with these issues. Let people know how it can benefit their agencies and their work. 34

35 Let the audience know that SARTs can have a variety of members, but at their core they include prosecutors, law enforcement, crime lab, advocacy and forensic examiners. If you like, modify the diagram to include other partners you would like to be involved. 35

36 Use this as an opportunity to elaborate on the victim centered approach to sexual violence. Explain how having a victim centered approach can lead to more reports, better investigations, more convictions and better healing for the survivor. 36

37 Review these benefits with the participants. 37

38 Ask the participants to reflect on whether they felt like there might be more benefits that were not listed. Write down ideas as they come out. Compare these responses to the introductions exercise. 38

39 39

40 Use this time to share information about the SART Toolkit and other resources that are available to guide your team. If you are able, print out copies of the toolkit and distribute them to each person present. Also, consider giving a handout that lists other SART resources. 40

41 The structure of this toolkit is based on an 8 step model. This model is derived from research conducted by FCASV and draws on models used in other states such as California, Minnesota, Washington, Oregon, and Texas. Fundamentally, the model emphasizes victim-centered approaches to sexual violence treatment, prevention, and education. The steps were designed to be straightforward and applicable to both rural and urban communities. FCASV recognizes that many communities are struggling to do more with less, and this model exhibits cost-free alternatives to building and maintaining a SART. While the model does have steps 1-8 listed, it is important to remember that the steps do not necessarily need to be completed sequentially. For example, community A may have had a long established SART that has seen a marked decrease in participation and thus decides to skip steps 1 and 2 and go right to step 3, while community B may be just starting a SART and need to start right at step 1. It is best for each community to start simple and build from there. 41

42 Spheres of Influence Activity (see SART Toolkit, pages 13 and 41) It is important that core members understand their relationship to one another and how each individual agency mission contributes to the overall SART. One tool that can be used to help define this relationship is the Spheres of Influence. To complete the Spheres of Influence exercise, complete the following steps: 1. Draw a large circle in the center of a piece of paper and label it with your SART name. 2. Draw smaller circles that overlap the edges of larger circle. Write the names of the core members in the smaller circles. 3. Have each core member write down their mission in regards to sexual assault services. For example, a law enforcement agency may have the mission to investigate crimes, provide referrals, and seek justice. 4. Compare the missions of each core member and discuss the commonalities and differences. 42

43 Utilize this slide as a framework for discussing the assessment of response services. You might facilitate with an activity such as the example provided below. One of the goals of SART is to analyze our local systems response to look for areas of excellence as well as areas of improvement. In small groups, please answer the following questions to help guide us towards some common goals for our SART. What do you view as being the most challenging aspect of working sexual battery cases? What is the most challenging part of working with survivors? Does your agency have a policy for working with victims of sexual battery (or sexual violence)? What is strength in your agency for responding to these crimes? What is an area that could use improvement? What is the number one need in our community in regards to sexual violence? Upon completion, facilitate discussion of these responses with the whole group. 43

44 Use this time to assess the willingness of the group to proceed with further developing a SART. Ask the participants to write down what they will do to support SART development in the next two weeks, two months and six months. Collect these responses and use this information to conduct follow up. Before you end the meeting, establish the next meeting time, date and location and be sure to get everyone s contact information so you can send them notes and notifications. 44

45 Appendix F - Trauma Informed Sexual Assault Investigations Outline and Objectives Intricacies of Sexual Assault Objectives: State 3 reasons why most victims don t report Explain why reporting victims may not divulge everything at once Neurobiology of Trauma Objectives Describe the function of the prefrontal cortex (use of reason, language, managing emotions, awareness of time/sequence) during normal activities. Explain how trauma impairs the prefrontal cortex and causes the survival part of the brain to kick in. Summarize how normal and traumatic memories are encoded and recalled differently Describe tonic immobility and how it affects victims during an assault. Explain how biological response to trauma affects victims demeanor and actions after an assault. Signs of Lying or Signs of Trauma? Objectives Comparing signs of lying with signs of trauma, explain how additional investigation is required to determine what transpired. Describe how preconceptions of how a victim s behavior indicates truthfulness can negatively affect a case. Staying Offender Focused Objectives List at least 3 vulnerabilities offenders exploit to target victims. Explain how serial offenders commit the largest number of assaults and engage in crossover offending. Describe how the perpetrator s brain reacts differently during an assault than the victim s and how that affects memory. 45

46 Trauma Informed Response Objectives Explain how officer verbal and nonverbal behavior during the interview affects victim s physiological reactions and ability to answer questions. Decide on an attitude or behavior change that will affect the next victim interview you conduct. Forensic Experiential Trauma Interview (FETI) Objectives Explain the importance of using the term able to and using open-ended questions. Describe the reason for asking sensory questions. Explain how to use evidence gathered to corroborate the victim s account. Using a live demonstration, write down at least three pieces of sensory evidence and how it could be corroborated in the investigation. Practice FETI Objectives Using the FETI model, conduct an interview with open-ended, sensory based questions. Demonstrate verbal and non-verbal behaviors that empower victims and establish a sense of connection. Critique a role play providing specific feedback on how well verbal and nonverbal behaviors put victims at ease and gave them control of the interview and how well FETI questions elicited sensory memories/evidence. Documenting FETI Evidence in Reports Objectives Explain the importance of using the victim s own language, capturing feelings and preserving quotes when writing reports. Contrast the language of consent and the language of sexual assault in a report and state how it could affect the outcome of an investigation. 46