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Final Pediatric Forensic Medical Record
WellSpan Health
York Hospital
Gettysburg Hospital
Forensic Medical Record
Adult/Adolescent
Form ED-129 R-5/2012
WellSpan Health Forensic Medical Record
York Hospital
Gettysburg Hospital
Pediatric
Form 4430 R-5/2012
Consent for Collection and Release of Evidence and Information
Additional Information
The examiner handling your case is:___________________________________________________
Confidential Document
A. Examiner Information
If you need to reach your examiner:
York: 717-851-2311
Gettysburg: 717-337-4299
Print Name of Examiner: _______________________________________
Signature
Examiners are not on-site at all times, please leave a message and someone will get back to you by the next business
day. If you have any questions about the evidence kit “results” including questions about drug facilitated kits
please contact the Law Enforcement agency you’re working with.
The victim services center in your area is:
YWCA Victim Assistance Center (717)854-3131
Survivors (717) 334-9777
Initials
Start Time
B. Reporting and Authorization
1.
Agencies Contacted:
Medical Advocate
Child Protective Services
Other
ChildLine
2. Report to police:
The Police Department Notified: _____________________________________
Department Phone Number: ______________________
With your permission, a nurse will contact you to check on your status  Yes  No
Phone number to call__________________________ OK to leave a message  Yes
 No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
____________________________________________
____________________________________________
____________________________________________
If no, why_______________________________________
____________________________________________
C. Patient Information
Additional Instructions:_________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
•
(Initial)
_______
(Initial)
_______
I understand that hospitals and health care providers have a duty to report certain crimes to law enforcement.
I have been informed that victims of crime are eligible to submit crime victim claims to the State Victims of Crime
Restitution Fund.
D. Patient Consent
•
This information is a guide to your care following an examination for sexual assault and is to be used in conjunction with
any additional information provided to you by your examiner and/or primary healthcare provider. Please bring discharge
instructions to your follow up appointment.
•
I understand that a forensic medical examination for evidence of sexual assault at public expense can, with my
consent, be conducted by a health care professional to discover and preserve evidence of the assault. I understand that
collection of evidence may include photographing injuries and that these photographs may include the genital area.
Discharge Instructions Provided
•
If conducted, the report of the examination and any evidence obtained will be released to law enforcement authorities
or any other investigating agencies.
•
I understand that I may withdraw consent at any time for any portion of the examination.
•
I understand that data without patient identity may be collected from this report for education and/or epidemiological
studies.
Signature
Initials
End Time
Signature_________________________________________________
 Patient
 Parent

(Initial)
______
(Initial)
______
(Initial)
______
(Initial)
______
Guardian
Printed Name (of above)_____________________________________________ Date_______ Time_______
If Patient is 14 years or older patient signature_________________________________________________
Printed Name (of above)___________________________________________________ Date_______ Time_______
Witness_________________________________________________________ Date_______ Time_______
Initials________/Date_______
Page 28 of 28
Initials:_________ /Date:__________
154 Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Page 1 of 23
Appendices
155