To assist with DNA profile interpretation, what gender was the survivor assigned at birth?

Male Female

Did the survivor have sexual contact with anyone other than the assailant in the week prior to the assault?

Yes No

If YES, was it within the last 120 hours? Yes No

If YES, how many hours prior to the assault?

If YES, was a condom used? Yes No

If DNA is recovered, sexual contacts in the week prior to the assault may be requested to provide a DNA sample to exclude them.

After assault but prior to evidence collection, the survivor has:

Douched Wiped/Washed Bathed Showered Urinated Defecated Vomited Had Food or Drink Brushed Teeth or Used Mouthwash Changed Clothes Changed Underwear Smoked/Vaped Swam None of the Above

Was the survivor’s clothing worn?

Before the incident	Yes No	Unknown

After the incident	Yes No	Unknown

Both before and after	Yes No	Unknown

How much time elapsed between the sexual assault and the examination?

Number of assailants	1	2	3	4	Unknown

At the time of the assault was:

Lubricant used during incident?	Yes	No	Unknown

Condom used during incident?	Yes	No	Unknown

Tampon present during incident?	Yes	No	Unknown

Survivor Menstruating?	Yes	No	Unknown

Reported perpetrator menstruating?	Yes	No	Unknown

Did choking/strangulation occur?	Yes	No	Unknown

Oral penetration?	Yes	No	Unknown

Penis	Digital	Mouth	Object	Unknown

Anal penetration?	Yes	No	Unknown

Penis	Digital	Mouth	Object	Unknown

Sexual organ penetration?	Yes	No	Unknown

Penis	Digital	Mouth	Object	Unknown

Did ejaculation occur?	Oral	Sexual organ	Anus	Unknown

Other (specify where)

Was there oral contact by the perpetrator on any portion of the survivor’s body?

Yes No Unknown

If YES, specify:	How? (licked, bit, etc.)	Oral contact where?

Was the perpetrator injured during the assault?	Yes No Unknown

If YES, specify how and where:

Did the survivor lose consciousness during the assault? Yes No Unknown

Is it suspected that drugs/alcohol may have been involved? Yes No

If YES, indicate what was involved: Drugs Alcohol Both

If YES, approximate date and time when they may have been taken:

Date and time of sample collection: