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DoD SEXUAL ASSAULT FORENSIC EXAMINATION REPORT

PRIVACY ACT STATEMENT
AUTHORITY: Section 301 of Title 5 U.S.C. and Chapter 55 of Title 10 U.S.C.; DoDD 6495.01, Sexual
Assault Prevention and Response (SAPR) Program; and DoDI 6495.02 Sexual Assault Prevention and
Response Program Procedures.
PRINCIPAL PURPOSE(S): Information on this form will be used to document the medical/forensic
examination of the sexual assault victim. The DD Form 2911 also documents the reporting preference
(Restricted or Unrestricted) of the sexual assault victim as part of the sexual assault prevention and
response program.
ROUTINE USE(S): None.
DISCLOSURE: Completion of this form is voluntary; however, failure to complete this form with the
information requested impedes the effective management of care and support required by the
procedures of the sexual assault prevention and response program.	Patient Identification
	Patient Identification

Sensitive Information Document

PART I (NOTE: Conduct a SAFE for up to one full week following a sexual assault, or longer if circumstances dictate.)

A. GENERAL INFORMATION (Print or type)

Name of Medical Facility:

1a.

NAME OF PATIENT (Last, First, Middle Initial)

b. PATIENT ID NUMBER

2a.

ADDRESS

b. CITY

c. COUNTY

d. STATE

e. ZIP CODE

f. TELEPHONE (Include Area Code)

(1) Home:

(2)

Work:

3a.

AGE

b. DATE OF BIRTH

c. GENDER (X)

d. ETHNICITY (X)

e. RACE (X)

(YYYY/MM/DD)

(1) Hispanic or

(1) American Indian/

(3) Black or African

(5) Native Hawaiian/

Latino

Alaska Native

American

Other Pacific Islander

(2) Not Hispanic or

(2) Asian

(4) White

Latino

4a. ARRIVAL DATE (YYYY/MM/DD)

b. TIME

5a. DISCHARGE DATE (YYYY/MM/DD)

b. TIME

B. NOTIFICATION AND AUTHORIZATION:

Location of Assault:			Jurisdiction:
	On Installation	Off Installation		City	County
	On Installation	Off Installation		City	County

Civilian or Foreign Assisting Agency:

Other

1a. NAME OF SEXUAL ASSAULT RESPONSE COORDINATOR (SARC) (Last, First, Middle Initial)

b.TELEPHONE (Include Area Code)

2a. NAME OF SEXUAL ASSAULT FORENSIC EXAMINER

(Last, First, Middle Initial)

b. RANK

c. TITLE

d.TELEPHONE (Include Area Code)

3a. NAME OF VICTIM ADVOCATE (VA) (Last, First, Middle Initial)					b. TELEPHONE (Include Area Code)

4a. NAME OF MILITARY CRIMINAL INVESTIGATIVE OFFICER (UNRESTRICTED REPORT)					b. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)

c. AGENCY				d. ID NUMBER		e. DATE (YYYY/MM/DD)

5a. NAME OF SERVICE DESIGNATED EVIDENCE COLLECTING OFFICER (RESTRICTED REPORT)						b. TELEPHONE (Include Area Code)
(Last, First, Middle Initial)

c. AGENCY			d. ID NUMBER	e. DATE (YYYY/MM/DD)	f. TIME	g. RESTRICTED REPORT
						CONTROL NUMBER (RRCN)

C. REPORTING INFORMATION

1. In unrestricted reporting, I understand that Military Medical Treatment Facilities and Healthcare Providers are required by Department of							(Initial)
Defense regulations to report sexual assaults to Military Criminal Investigative Organization authorities (e.g., CID, NCIS, AFOSI). Under
these circumstances, the report must state the name of the injured person, current whereabouts, and the type and extent of injuries.
In Restricted reporting, I understand that Military Medical Treatment Facilities and Healthcare Providers are required by Department of
Defense regulations to report sexual assaults to the Sexual Assault Response Coordinator (SARC).

2. The Sexual Assault Response Coordinator (SARC) and/or Victim Advocate (VA) have explained the difference between Unrestricted and							(Initial)

Restricted Reporting options. I have elected:
	UNRESTRICTED REPORTING	RESTRICTED REPORTING (Only applicable to Active Duty, and Reserve and National
	UNRESTRICTED REPORTING

Guard in active service or inactive duty training)

Note: Military dependents under age 18 who have been sexually assaulted by either parent and/or caregiver are not covered under the sexual assault restricted reporting policy.

(Initial)

3.I understand what my options are and do not have questions.

DD FORM 2911, SEP 2011

Page 1 of 14 Pages

Adobe Professional 8.0

D. PATIENT CONSENT

1. I understand that the Sexual Assault Forensic Examination		YES


(also known as a "SAFE") that I am about to undergo is
(also known as a "SAFE") that I am about to undergo is
optional. When I give my consent, a healthcare		NO
professional may examine me to find and collect evidence
professional may examine me to find and collect evidence

of an assault. I understand that as part of the examination,	(Initial)
the provider can collect specimens to include my hair, urine
and/or blood, both now and at a later date, if necessary.
			Patient Identification
					(Initial)
2. I understand that I may withdraw my consent at any time for any portion of the examination and that it				YES


will not impact my right to medical care.				NO
will not impact my right to medical care.



					(Initial)
3. I understand that collection of evidence may include photographing injuries and that these photographs				YES


may include the genital area.				NO
may include the genital area.



					(Initial)
4. I understand that samples of my blood and/or urine may need to be tested for drugs as part of my				YES
treatment. I also understand that testing for drugs will also show prescriptions, other drugs, and				YES


alcohol that I have voluntarily consumed. I understand that illegal drugs or alcohol (if I am under
age 21) in my body could be used to show that I engaged in misconduct if I am a Service member.				NO
I consent to this testing and the release of the result to law enforcement.


					(Initial)

5. I understand that some of the information that I provide may be collected for health and forensic				YES
purposes and provided to health authorities and other qualified persons for a valid educational or				YES



scientific interest and/or epidemiological studies. However, none of my personally identifying data				NO
(name, patient identification number, etc.) will be disclosed for these purposes.				NO



					(Initial)
					(Initial)
				YES

6.I hereby consent to a sexual assault medical forensic examination (SAFE).

		(Initial)
7. If I have elected to make an Unrestricted Report, I understand and consent to the release of my records		YES


and all evidence collected from this exam to law enforcement.		NO

8. If I have elected to make a Restricted Report, I understand that my records and all evidence collected				YES	(Initial)
				YES


	should not be reviewed or tested unless I choose to convert to an Unrestricted Report.			NO




9a.	PATIENT SIGNATURE		b. DATE		c. TIME
			(YYYY/MM/DD)

10.	PATIENT PARENT OR GUARDIAN (If applicable)
a. SIGNATURE		b. ADDRESS (If different from patient) (Include ZIP Code)	c. DATE		d. TIME
			(YYYY/MM/DD)

11.	WITNESS TO PATIENT SIGNATURE
a. SIGNATURE		b. ADDRESS (Include ZIP Code)	c. DATE		d. TIME
			(YYYY/MM/DD)

DD FORM 2911, SEP 2011

Page 2 of 14 Pages

E. PATIENT HISTORY

1a. NAME OF PERSON PROVIDING HISTORY (Last, First, Middle Initial)

b. RELATIONSHIP TO PATIENT				c. DATE (YYYY/MM/DD)	d. TIME

2. PERTINENT MEDICAL HISTORY						Patient Identification
a. LAST MENSTRUAL PERIOD	b. Any recent (60 days) anal-genital injuries, surgeries, diagnostic procedures, or medical treatment that may affect the interpretation of
		current physical findings? (If yes, describe)
			No
			No
			Yes
			Yes

c. Any other pertinent medical condition(s) that may affect the interpretation of current physical findings? (If yes, describe)

Yes

d. Any pre-existing physical injuries? (If yes, describe)

Yes

3. PERTINENT NON-ASSAULT RELATED HISTORY

a. Other non-assault sexual activity within past 5 days? Do NOT record any other information regarding sexual history on this form.

Yes

Unsure

If yes or unsure, complete items b. through f. below. If no, then check the "No" box to the left and proceed to item 4.

(X and complete as applicable)

Yes

Unsure

(If Yes)

b. Anal (within past 5 days)?

When?

c. Vaginal (within past 5 days)?

When?

d. Oral (within past 5 days)?

When?

e. Did ejaculation occur?

Where?

f. Was a condom used?

4. POST-ASSAULT HYGIENE/ACTIVITY

Not Applicable if over 5 days

(X and complete as applicable)

Yes

a. Urinated

Brushed teeth

b. Defecated

Gargled/mouthwash

c. Genital or body wipes (If yes, describe)

Vomited

k. Ate or drank

d. Douched (If yes, with what)

l. Used cream/ointment/lotion on body part involved in assault (If yes,

describe)

e. Removed/inserted

m. Changed clothing (If yes, describe)

Tampon

Diaphragm

Nuva ring

Oral gargle/rinse

n. Changed body piercings (If yes, describe)

Bath/shower/wash

F. ASSAULT HISTORY

1a. DATE OF ASSAULT(S) (YYYY/MM/DD) 2. LOCATION AND PERTINENT PHYSICAL SURROUNDINGS

b. TIME

3. PHYSICAL EFFECTS OF ASSAULT. If injuries are described or if remarkable findings or possible trauma are observed, please photograph.

a. Non-genital injury, pain and/or bleeding (including tenderness). (If yes, describe.)

Yes

b. Genital/rectal injury, pain and/or bleeding (including tenderness). (If yes, describe.)

Yes

4. INJURIES INFLICTED UPON THE ASSAILANT(S) DURING ASSAULT? (If yes, describe injuries, possible locations on the body, and how they were inflicted.)

Yes

5a. NUMBER OF ASSAILANT(S)	b. ASSAILANT(S) RELATIONSHIP TO VICTIM (Indicate/number all that apply)
		Stranger	Acquaintance	Relative (Specify)
		Stranger	Acquaintance	Relative (Specify)

		Other (Specify)

DD FORM 2911, SEP 2011

Page 3 of 14 Pages

G. PATIENT'S DESCRIPTION OF THE ASSAULT

Please record the patient's description of the assault.

Add additional pages if necessary.

Patient Identification

DD FORM 2911, SEP 2011

Page 4 of 14 Pages

H. ACTS DESCRIBED BY PATIENT

- Describe any penetration of the genital, anal or oral opening, no matter how slight or brief.

- Type of sexual intercourse (oral, vaginal, anal).

- If more than one assailant, identify by number.

Patient Identification

1. PENETRATION OF VAGINA BY

Yes

Attempted

Unsure

Describe:

a. Penis

b. Finger

c. Object (If yes, describe the object)

2. PENETRATION OF ANUS BY

Yes

Attempted

Unsure

Describe:

a. Penis

b. Finger

c. Object (If yes, describe the object)

3. ORAL COPULATION OF GENITALS

Yes

Attempted

Unsure

Describe:

a. Of patient by assailant

b. Of assailant by patient

4. ORAL COPULATION OF ANUS

Yes

Attempted

Unsure

Describe:

a. Of patient by assailant

b. Of assailant by patient

5. NON-GENITAL ACT(S)

Yes

Attempted

Unsure

Describe:

a. Licking

b. Kissing

c. Suction injury

d. Biting

e. Strangulation/choking

6. OTHER ACT(S) (Describe)

7. DID EJACULATION OCCUR?

Yes

Unsure

(If yes, location(s))

Mouth

Rectum

Other (note location(s))

Vagina

Body surface

Genitals

On clothing

Anus

On bedding

8. CONTRACEPTIVE OR LUBRICANT PRODUCT(S)

Yes

Unsure

Describe Type/Brand, if known:

a. Condom used?

b. Lubricant used?

c. Other Contraceptive used?

DD FORM 2911, SEP 2011

Page 5 of 14 Pages

I. GENERAL PHYSICAL EXAMINATION

- Record all findings using diagrams, legend, and a consecutive numbering system.

- If injuries are described or if remarkable findings or possible trauma are observed,

please photograph.

1a. Weight

b. Blood

Pressure

c. Pulse

d. Resp

e. Temp

f. Pulse Oxygen

2a. Exam Started

b. Exam Completed

Date (YYYYMMDD)

Time

Date (YYYYMMDD)

Time

Patient Identification

3. Describe general physical appearance.

4. Describe general demeanor. (Including affect, behavior

5. Describe condition of clothing upon

(Use observations, not conclusions.)

and orientation. Use observations, not conclusions.)

arrival. (If the patient has not changed after

the assault)

6. Collect outer and underclothing if indicated.

Conduct a physical examination. Use the history obtained earlier to guide your examination and recovery

Not indicated

of evidence.

Findings

No Findings Observed

8. Scan the entire body with an Alternate Light Source (such as a Wood's Lamp). Collect dried and moist secretions, stains, and foreign materials from the body.

Label box and envelope with the location of the collection.

Findings

No Findings Observed

9. Was there a history of scratching?

Yes

Unsure

If yes or unsure, collect fingernail clippings. If there is not enough fingernail to clip, then swab

fingernails.

10. Was there a history of kissing, licking or sucking parts of the body?

Yes

Unsure

If yes or unsure, collect swabs of the body areas that were believed to be contacted by the suspect's mouth. (Head and genitals are addressed in the next sections.)

Diagram A

Diagram B

LEGEND: TYPES OF FINDINGS. RECORD ALL CLOTHING AND SPECIMENS COLLECTED IN SECTION O.

Abrasion

Burn

Deformity

Foreign Body

Moist Secretion

Petechiae

Swelling

ALS Alternate Light CS

Control Swab

Dry Secretion

Induration

Other Foreign

Potential Saliva

Toluidine Blue

Source

Contusion (bruise)

Erythema (redness) IW

Incised Wound

Materials (describe)

SHX Sample Per History

Tenderness

Bite

Debris

F/H

Fiber/Hair

Laceration

Other Injury

(describe)

Suction Injury

V/S

Vegetation/Soil

Locator #

Type

Description

Locator #

Type

Description

DD FORM 2911, SEP 2011

Page 6 of 14 Pages

J.HEAD, NECK, THROAT AND ORAL EXAMINATION

-Record all findings, including tenderness and pain, using diagrams, legend, and a consecutive numbering system.

-If injuries are described or if remarkable findings or possible trauma are observed, please photograph.

1.Examine the face, head, hair, scalp, neck and throat for injury and foreign materials.

		Findings		No Findings Observed

2.Collect dried and moist secretions, stains, and foreign materials from the face, head,

hair, neck, throat and scalp.		Findings		No Findings Observed

3.Examine the oral cavity for injury and foreign material (If indicated by assault history).

Collect foreign materials.

Exam done:		Not applicable		Yes		Findings		No Findings Observed

Patient Identification

4.Collect at a minimum 1 external mouth swab and 2 swabs from the oral cavity (if indicated by history).

5. Collect head hair combing or brushing.

Diagram C

Diagram D

Diagram E

Diagram F

LEGEND: TYPES OF FINDINGS. RECORD ALL SPECIMENS COLLECTED IN SECTION O.

Abrasion

Burn

Deformity

Foreign Body

Moist Secretion

Petechiae

Swelling

ALS Alternate Light CS

Control Swab

Dry Secretion

Induration

Other Foreign

Potential Saliva

Toluidine Blue

Source

Contusion (bruise)

Erythema (redness)

Incised Wound

Materials (describe)

SHX

Sample Per History

Tenderness

Bite

Debris

F/H

Fiber/Hair

Laceration

Other Injury (describe)

Suction Injury

V/S

Vegetation/Soil

Locator #

Type

Description

Locator #

Type

Description

DD FORM 2911, SEP 2011

Page 7 of 14 Pages

K.GENITAL EXAMINATION - FEMALE

-Record all findings, including tenderness and pain, using diagrams, legend, and a consecutive numbering system.

-If injuries are described or if remarkable findings or possible trauma are observed, please photograph.

1. Examine the inner thighs, external genitalia, and perineal area.

	If there are findings, describe (including location).			Findings	No Findings
	If there are findings, describe (including location).
. (If available and appropriate, consider the use of
. (If available and appropriate, consider the use of					Observed
	toluidine blue dye.)		Clitoral hood and		Observed
	toluidine blue dye.)
		Abdomen
		Abdomen	surrounding area
			surrounding area
		Thighs	Periurethral tissue/
		Thighs	urethral meatus
			urethral meatus
		Perineum	Hymen
		Labia majora	Fossa navicularis
		Labia majora	Fossa navicularis
		Labia minora	Posterior fourchette
		Labia minora	Posterior fourchette

Patient Identification

2. Scan the area with an Alternate Light Source. Collect dried and moist

secretions, stains, and foreign materials.		Findings		No Findings Observed

3. Collect pubic hair combing or brushing. If there is no pubic hair, conduct an external swab of genitalia.

4. Examine the vagina and cervix. If there are findings, describe (including

5. Examine the buttocks, anus, and perineum.

location). (If available and appropriate, consider the use of toluidine blue dye.).

a. Findings from buttocks, anus, or perineum. If there are findings, describe

Findings

No Findings Observed

(including location) (If available and appropriate, consider use of toluidine blue dye.).

Yes

No Findings Observed

b. Collect dried and moist secretions, and foreign materials.

a. Collect the following swabs: 2 pubic mound (if there is no pubic hair), 2 vaginal, and

Findings

No Findings Observed

2 cervical.

c. Collect 2 swabs of the perineum.

d. Collect 2 anal swabs.

6. Conduct a rectal exam (using anoscope if possible) if rectal injury is suspected or if there is any sign of rectal bleeding.

a. Rectal exam done:	Yes	Not applicable
b. Rectal bleeding:	No	Yes

c. Was an anoscopic exam done?		No	Yes

d. If exam was done, what position was used?			Supine Lithotomy

e. If exam was done, describe findings:

f. Collect a rectal swab if indicated.

Other (describe)

Diagram G

Diagram H

Diagram I

Diagram J

LEGEND: TYPES OF FINDINGS. RECORD ALL SPECIMENS COLLECTED IN SECTION O.

Abrasion

Burn

Deformity

Foreign Body

Moist Secretion

Petechiae

Swelling

ALS Alternate Light

CS Control Swab

Dry Secretion

Induration

Other Foreign

Potential Saliva

Toluidine Blue

Source

Contusion (bruise)

Erythema (redness)

Incised Wound

Materials (describe)

SHX

Sample Per History

Tenderness

Bite

Debris

F/H

Fiber/Hair

Laceration

Other Injury (describe)

Suction Injury

V/S

Vegetation/Soil

Locator #

Type

Description

Locator #

Type

Description

DD FORM 2911, SEP 2011

Page 8 of 14 Pages

L.GENITAL EXAMINATION - MALE

-Record all findings, including tenderness and pain, using diagrams, legend, and a consecutive numbering system.

-If injuries are described or if remarkable findings or possible trauma are observed, please photograph.

1. Examine the inner thighs, external genitalia, and perineal area.

If there are findings, describe (including location). (If available and appropriate,

consider the use of toluidine blue dye.)				Findings	No Findings Observed

	Abdomen	Urethral meatus	Glans
	Thighs	Shaft

			Testes

	Foreskin	Scrotum

Patient Identification

2. Circumcised:

Yes

3. Scan the area with an Alternate Light Source (such as a Wood's Lamp). Collect dried and moist secretions,

stains, and foreign materials.			Findings		No Findings Observed

4.Collect pubic hair combing or brushing. If no pubic hair, conduct external swab at base of penis.

5.If indicated by assault history, collect the following swabs: 2 penile and 2 scrotal.

6.Examine the buttocks and perineum (if indicated by history). a. Findings from buttocks, anus, or perineum.

Yes

None Observed

b. Collect dried and moist secretions, and foreign materials.

Findings

No Findings Observed

If there are findings, describe (including location). (If available and appropriate, consider the use of toluidine blue dye.)

7.Collect 2 anal swabs.

8.Conduct a rectal exam (using anoscope if possible) if rectal injury is suspected or if there is any sign of rectal bleeding.

a.Rectal exam done?

b.Rectal bleeding:

Yes

No	e. If exam was done, describe findings:

None Observed

c. Was an anoscopic exam done?		Yes

d. If exam was done, what position was used?

Other (describe)

Supine

Diagram K

Diagram L

Diagram M

Diagram N

LEGEND: TYPES OF FINDINGS. RECORD ALL SPECIMENS COLLECTED IN SECTION O.

Abrasion

Burn

Deformity

Foreign Body

Moist Secretion

Petechiae

Swelling

ALS Alternate Light

CS Control Swab

Dry Secretion

Induration

Other Foreign

Potential Saliva

Toluidine Blue

Source

Contusion (bruise)

Erythema (redness)

Incised Wound

Materials (describe)

SHX

Sample Per History

Tenderness

Bite

Debris

F/H

Fiber/Hair

Laceration

Other Injury (describe)

Suction Injury

V/S

Vegetation/Soil

Locator #

Type

Description

Locator #

Type

Description

DD FORM 2911, SEP 2011

Page 9 of 14 Pages

M. TOXICOLOGY

Toxicology examples must be collected as soon as possible due to the

limited time frame in which they can be collected. If the assault happened within

96 hours of the examination and the answer to any of these questions is Yes or

Unsure, use the DoD Toxicology Kit.

Loss of memory? (If yes, describe)

Yes

Patient Identification

Lapse of consciousness? (If yes, describe)

Yes

Unsure

3. Vomited? (If yes, describe. Include location and number of

Yes

times.)

4.a. Voluntary ingestion of alcohol/drugs?

Yes

Unsure

b. Involuntary ingestion of alcohol/drugs?

Yes

Unsure

If yes:

Alcohol

Drugs

If yes:

Alcohol

Drugs

Was a clinical toxicology lab conducted?

Yes

6. FOR UNRESTRICTED REPORTS: Was a DoD Toxicology Kit completed?

Yes

N. RECORD EXAM METHODS

Direct visualization only

Yes

Toluidine Blue Dye

(If Other, describe)

Yes

Alternate Light Source

Yes

6. Anoscopic exam

Yes

Digital Camera

Yes

7. Vaginal speculum exam

Yes

Colposcope or Other Magnifier

Yes

8. Other

Yes

O. OBSERVATIONS. Please describe your observations.

DD FORM 2911, SEP 2011

Page 10 of 14 Pages

P. EVIDENCE COLLECTED

Yes

Time Completed

TOXICOLOGY KIT

Completed By

Released To

Patient Identification

CLOTHING

Yes

Time Completed

Completed By

Released To

a. Undergarments placed in evidence kit

b. Clothing placed in bags

OTHER:

Yes

Time Completed

Completed By

Released To

Swabs, suspected blood

Dried secretions

Fiber/loose hairs

Vegetation

Soil/debris

Swabs/suspected semen

g. Swabs/suspected saliva

h. Swabs/Alternate Light Source area(s)

Fingernail cuttings

Fingernail scrapings/swabbings

Matted hair cuttings

Pubic hair combings/brushings

m. Intravaginal foreign body (If yes, describe)

n. Other types (If yes, describe)

4. ORAL, GENITAL, RECTAL SAMPLES

# Swabs

Time Completed

Completed By

# Swabs

Time Completed

Completed By

a. External oral swab(s)

Perineal swab(s)

b. Oral cavity swab(s)

Anal swab(s)

c. Vaginal swab(s)

Rectal swab(s)

Other

d. Cervical swab(s)

(If yes, describe)

e. Pubic mound swab(s)

5. REFERENCE SAMPLES

Yes

Time Completed

Completed By

Yes

Time Completed

Completed By

a. Blood Card

d. Other (describe)

b. Known Head Hair

c. Known Pubic Hair

DD FORM 2911, SEP 2011

Page 11 of 14 Pages

Q. PHOTO DOCUMENTATION METHODS

TYPE OF CAMERA

35 mm

Polaroid

Digital

Colposcope

Other

DISPOSITION OF FILM/DISK

Patient Identification

PHOTO LIST

Photo Number

Description of Photo

R. OTHER DOCUMENTS INCLUDED - If there are any other documents included with this report, please list:

S. PERSONNEL INVOLVED - Print names.

HISTORY TAKEN BY

Telephone (Include Area Code)

2. EXAM PERFORMED BY

Telephone (Include Area Code)

SPECIMENS LABELED AND SEALED BY

Telephone (Include Area Code)

4. ASSISTED BY

T. EVIDENCE DISTRIBUTION

TOXICOLOGY KIT GIVEN TO:

EVIDENCE KIT AND

BAGS GIVEN TO:

ITEMS RETURNED TO PATIENT (describe)

OTHER (describe)

Given to:

U. PERSON RECEIVING EVIDENCE - For Unrestricted Report - MCIO; for Restricted Report - See Service Policy.

SIGNATURE

PRINTED NAME AND ID NUMBER

AGENCY

DATE (YYYYMMDD)

5. TELEPHONE (Include Area Code)

DD FORM 2911, SEP 2011

Page 12 of 14 Pages

DoD SEXUAL ASSAULT FORENSIC EXAMINATION REPORT

PART II - DoD TOXICOLOGY KIT - FOR UNRESTRICTED REPORTS ONLY

BLOOD AND URINE SPECIMEN COLLECTION INSTRUCTIONS

Notes:

(A)This kit is to be used in conjunction with a DoD Medical Forensic Examination Kit when the patient indicates that there was memory loss, lapse of consciousness, involuntary or voluntary ingestion of drugs or alcohol, or if toxicology testing is otherwise indicated.

(B)Collect both blood and urine specimens in all cases.

(C)Urine samples should be collected from the victim as soon as possible due to the short window of detection for many of the drugs (including alcohol) involved in sexual assault.

(D)Based on timing of evidence pick up, refrigerate the sealed kit. However, if you are in a deployed or natural disaster environment that does not have refrigeration, it will be unlikely to preserve specimen.

STEP 1: Fill out the information requested on the Victim Information Form (next page).

BLOOD SPECIMEN COLLECTION

Note: Blood specimen collection must be performed only by a physician, registered nurse or trained phlebotomist.

STEP 2: Cleanse the blood collection site with the alcohol-free prep pad provided. Following normal hospital/clinic procedure, collect blood using two 10 ml blood collection tubes with 100 mg of sodium fluoride and 20 mg of potassium oxalate. Allow blood tubes to fill to maximum volume.

Notes:

(A)Immediately after blood collection, assure proper mixing of anticoagulant powder by slowly and completely inverting the blood tube at least five times. Do NOT shake!

(B)Discard venipuncture needle(s) and prep pads as recommended by OSHA guidelines. Do NOT place the venipuncture needle(s) or prep pads in the specimen collection box.

STEP 3: Fill out all information requested on two of the three Specimen Security Seals provided. Then remove backing from the two Specimen Seals. Affix center of seals to the blood tube rubber stoppers, and press ends of seals down sides of the blood tubes, then place both filled and sealed blood tubes in specimen holder.

URINE SPECIMEN COLLECTION

STEP 4: Have subject void directly into the urine specimen bottle provided. A minimum of 60 ml is required.

STEP 5: After specimen is collected, replace cap and tighten down to prevent leakage.

STEP 6: Fill out the information requested on the remaining Specimen Security Seal. Affix center of seal to the bottle cap and press ends of seal down sides of bottle, then place urine bottle in specimen holder.

STEP 7: Place specimen holder inside the zip lock bag, then squeeze out excess air and close the bag. Place specimen holder in kit box.

Note: Do not remove liquid absorbing sheet from specimen bag.

STEP 8: Place DoD Toxicology Kit Victim Information form in Toxicology Kit. Retain a copy of the form with the SAFE Report.

STEP 9: Close kit box and affix kit box shipping seal where indicated.

STEP 10: Fill out all information requested on kit box top under "For Hospital Personnel".

STEP 11: Hand sealed kit to investigating agent.

Note: If the officer is not present at this time, place sealed kit in secure and refrigerated area, and hold for pickup by investigating officer. Work with law enforcement/investigating agent to ensure the CHAIN OF CUSTODY IS MAINTAINED.

MCIO or investigating agent should mail kit with Form 1323, Toxicological Request Form (found at: www.afip.org) to:

Armed Forces Medical Examiner

Division of Forensic Toxicology

Bldg 1102

1413 Research Boulevard

Rockville, MD 20850

EFFECTIVE 1 DEC 2011:

Armed Forces Medical Examiner

Division of Forensic Toxicology

Bldg 115

Purple Heart Drive

Dover AFB, DE 19902

DD FORM 2911, SEP 2011

Page 13 of 14 Pages

DoD TOXICOLOGY KIT

VICTIM INFORMATION FORM

FOR UNRESTRICTED REPORTS ONLY

Patient Identification

1.	VICTIM'S NAME (Last, First, Middle Initial)

2.	VICTIM'S DATE OF BIRTH (YYYY/MM/DD)

3a. DATE OF SPECIMEN COLLECTION (YYYY/MM/DD)					b. TIME

4.	IS VICTIM A SMOKER?
		Yes	No
		Yes	No


5.	IS VICTIM TAKING ANY PRESCRIPTION DRUGS?
		Yes	No
		Yes	No


a. IF YES, NAME OF DRUG(S)

b. DATE DRUG(S) LAST TAKEN (YYYY/MM/DD)					c. TIME

6.	IS VICTIM TAKING ANY OVER-THE-COUNTER DRUGS?
		Yes	No
		Yes	No


a. IF YES, NAME OF DRUG(S)

b. DATE DRUG(S) LAST TAKEN (YYYY/MM/DD)					c. TIME

7.	WHY IS DRUG SCREEN BEING REQUESTED?

8.	PERSON COLLECTING SAMPLE

a. NAME (Last, First, Middle Initial)				b. TITLE		c. DATE (YYYY/MM/DD)

DD FORM 2911, SEP 2011

COPY 1 - TO BE SENT WITH KIT TO AFIP

Page 14 of 14 Pages

DoD TOXICOLOGY KIT

VICTIM INFORMATION FORM

FOR UNRESTRICTED REPORTS ONLY

Patient Identification

1.	VICTIM'S NAME (Last, First, Middle Initial)

2.	VICTIM'S DATE OF BIRTH (YYYY/MM/DD)

3a. DATE OF SPECIMEN COLLECTION (YYYY/MM/DD)					b. TIME

4.	IS VICTIM A SMOKER?
		Yes	No
		Yes	No


5.	IS VICTIM TAKING ANY PRESCRIPTION DRUGS?
		Yes	No
		Yes	No


a. IF YES, NAME OF DRUG(S)

b. DATE DRUG(S) LAST TAKEN (YYYY/MM/DD)					c. TIME

6.	IS VICTIM TAKING ANY OVER-THE-COUNTER DRUGS?
		Yes	No
		Yes	No


a. IF YES, NAME OF DRUG(S)

b. DATE DRUG(S) LAST TAKEN (YYYY/MM/DD)					c. TIME

7.	WHY IS DRUG SCREEN BEING REQUESTED?

8.	PERSON COLLECTING SAMPLE

a. NAME (Last, First, Middle Initial)				b. TITLE		c. DATE (YYYY/MM/DD)

DD FORM 2911, SEP 2011

COPY 2 - TO BE MAINTAINED WITH SAFE REPORT

Page 14 of 14 Pages

Question	Answer
Form Name	Dd Form 2911
Form Length	15 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 45 sec
Other names	YYYYMMDD, DF, SHX, anoscopic

Dd Form 2911 – Fill Out and Use This PDF

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