Appendices
· Appendix 1 - Model for Sexual Assault Community Protocol
· Appendix 2 – Ohio SART Training Information
· Appendix 3- Ohio Crime Victims Handout and AGO Picking up the Pieces
· Appendix 4 – Sample Notification Letter for Hospitals/Facilities to send after Examining a Minor without Parent Consent
· Appendix 5 - Criteria for Ohio SAFE Program – Child Sexual Abuse Exams (Effective January 31, 2012)
o Competency requirements for Physicians conducting child sexual abuse exams
o Sexual Assault Nurse Examiner – Competencies for recognition in Ohio for Child Sexual Abuse Evaluation
o See above AGO forms under Ohio Child and Adolescent Sexual Abuse Protocol. Effective January 31, 2012, in order for the physician or SANE to receive reimbursement for the exam they have conducted, the AGO form must be submitted and approved prior to the exam.
· Appendix 6 – Patient Handouts
o Information You Should Know as A Sexual Assault Survivor
o Helping Your Child: A Note to Parents and Caregivers
o Caring for Yourself: A Note to Survivors
o After Care Information and Resources
o Document of Care
· Appendix 7- Sample Quality Assurance Tools
· Appendix 8 - Specific Knowledge and Skills Set Beneficial for Health Care Professionals Conducting a Forensic Exam
· Appendix 9 - Drug Facilitated Sexual Assault protocol
· Appendix 10 – Sexual Assault Evidence Collection Kit
o Kit Specifications
o Ordering Information
o Instructions, Forms and Labels
· Appendix 11 – Sample Medical History Form
· Appendix 12 – HIV
o Prophylactic Information
o Ohio Test Sites
o CDC – HIV Recommendations and Guidelines
· Appendix 13 – Emergency Contraceptives
o Terms
o Fact Sheet Sample – for obtaining consent
· Appendix 14 – Outline of the Criminal Justice System
· Appendix 15 – Ohio Attorney General Sexual Assault Forensic Examination Payment Program (AGO SAFE)
o Letter to the Hospital Administrators
o Billing Procedures
o Reimbursement Request Form
o For Sexual Assault Victim/Survivors – Information About Your Medical Bill
o Ohio Attorney General SAFE Program website.
· Appendix 16– Provisions within the Ohio Revised Code Dealing with Sexual Assault
· Appendix 17 - Emergency Medical Services Protocol for Sexual Assault
· Appendix 18 - Male Survivors of Sexual Assault
· Appendix 19 - Child Assault Reporting Guidelines
