ࡱ> `b_ Bbjbj?? ^F]]yyyyy$P\I402}"3D///////313/yww{/yy/dyy/w/@.yy/T>u.8/l/00.844(/y/www ?:   aTTACHMENT H California DCR PRISON RAPE ELIMINATION POLICY Post-SEXUAL Assault Information IR#/Victims Name & CDC # Interviewing StaffDate of Interview Did you Bathe/shower/wash YES  FORMCHECKBOX  NO  FORMCHECKBOX  Brush teeth YES  FORMCHECKBOX  NO  FORMCHECKBOX  Use mouthwash/gargle YES  FORMCHECKBOX  NO  FORMCHECKBOX  Eat YES  FORMCHECKBOX  NO  FORMCHECKBOX  Drink YES  FORMCHECKBOX  NO  FORMCHECKBOX  Urinate YES  FORMCHECKBOX  NO  FORMCHECKBOX  Have a bowel movement YES  FORMCHECKBOX  NO  FORMCHECKBOX  Change your clothes YES  FORMCHECKBOX  NO  FORMCHECKBOX  Where did the incident take place?________________________________________________________ How did it happen? ___________________________________________________________________ What type of act(s) occurred? ___________________________________________________________ Was there any penetration of anus/vagina or mouth by: Penis YES  FORMCHECKBOX  NO  FORMCHECKBOX  Finger YES  FORMCHECKBOX  NO  FORMCHECKBOX  Object YES  FORMCHECKBOX  NO  FORMCHECKBOX  Describe the object used: ______________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ How many times?_____________________________________________________________________ How long did it last?___________________________________________________________________ Were you threatened? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, describe. ______________________________________________________________________ Were you forced? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Did he/she help you? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Were you physically harmed in any other way? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, describe. ______________________________________________________________________ Did he/she touch or fondle you anywhere else? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, describe. ______________________________________________________________________ Did he/she use any type of lubrication? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, describe. ______________________________________________________________________ Where was it applied? _________________________________________________________________ Was he/she wearing any clothes? If yes, describe. YES  FORMCHECKBOX  NO  FORMCHECKBOX ___________________________________________________________________________________ What were you wearing? _______________________________________________________________ ___________________________________________________________________________________ Did you keep your clothes on? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If no, why? __________________________________________________________________________ Were there any distinguishable marks on his/her body? YES  FORMCHECKBOX  NO  FORMCHECKBOX If yes, describe where and location: ______________________________________________________ Were there any distinguishable marks on his/her genital area? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, describe where and location: ______________________________________________________ Did you see any pubic hair? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Is it the same color as the hair on his/her head? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Was he circumcised? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Was his penis erect when you saw it? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Did he ejaculate? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, where? _______________________________________________________________________ Did you ejaculate? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, where? _______________________________________________________________________ Do you know if he/she had anything to drink (inmate manufactured alcohol) or take any medication prior to the assault? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, what? _________________________________________________________________________ Did you have anything to drink (inmate manufactured alcohol) or take any medication prior to the assault? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, what?_________________________________________________________________________ What happened after the assault? ________________________________________________________ Did you clean up afterwards? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, what did you use? _______________________________________________________________ What did you do with it? _______________________________________________________________ Where is it now? _____________________________________________________________________ What did you do with the clothes you were wearing? _________________________________________ Have you ever been threatened before? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If yes, by whom, where, etc.? ___________________________________________________________ Have you ever engaged sexual activity with another individual of the same sex before? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Did you tell anyone else about this? 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Courier New"1h$ܦ$ܦ&I 'cP )Y4dw2QHX?+2/QUESTIONS TO ASK TO VICTIMS OF A SEXUAL ASSAULT JTabayoyong Leslie Leip(        Oh+'0$ 8D h t  '0QUESTIONS TO ASK TO VICTIMS OF A SEXUAL ASSAULT JTabayoyong Normal.dotm Leslie Leip2Microsoft Macintosh Word@F#@22@>u@>uI ՜.+,0( hp  'Dept of Corrections'  0QUESTIONS TO ASK TO VICTIMS OF A SEXUAL ASSAULT Title  !"#%&'()*+,-./012356789:;<=>?@ABCDEFGHIJKLMNPQRSTUVXYZ[\]^aRoot Entry FL%U>ucData $1Table44WordDocument^FSummaryInformation(ODocumentSummaryInformation8WCompObj`ObjectPool%U>u%U>u F Microsoft Word 97-2004 DocumentNB6WWord.Document.8