Sexual Assault Supplemental Report Form - International Association of Chiefs of Police

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Sexual Assault Supplemental Report Form
It is recommended that the Sexual Assault Supplemental Report be used in the reporting, recording and
investigation of all sexual assault incidents, for each and every incident reported
Supervisory review of all sexual assault cases is encouraged
This form is not intended for use when the victim is a minor
Agency
ORI
Incident #
Case #
Name of Person Who Contacted Police (optional on information reports)
Method Report Received
911 Call
Non-emergency number
Online
Other (describe)
Address of Person Who Contacted Police
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Relationship to Victim
Others Present with Victim During Interview
Location of Interview
Hospital
On Scene
At Department
Other (describe)
Dates
Date of Report (mm/dd/yyyy)
Time of Report
Date(s) of Incident (mm/dd/yyyy)
Time of Incident
From
To
Victim
Victim’s identifying or contact information may be exempt from disclosure under the Freedom of Information Act
and Crime Victim’s Rights Act or if this is a blind report.
Last Name
First Name
Middle Name
Any Aliases
Primary Language
Special Needs, Disability, Requests, etc.
Race/Ethnicity
Sex
Date of Birth (mm/dd/yyyy)
Height
Weight
M
F
Address
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Emergency Contact
Emergency Contact Telephone
Best Way to Safely Contact Victim
Victim Demeanor Observed at Time of Interview (select all that apply) Include detailed description in narrative
Other (describe)
Afraid/Fearful
Confused
Shaking/Trembling
Angry
Flat Affect
Tearful/Crying
Calm/Controlled
Nervous/Agitated
Withdrawn/Quiet/Flat Affect
Are there any injuries?
Y
N
Does the victim report pain?
Y
N
If yes, detail in narrative
Follow up needed
If yes, describe
Were weapons used to hurt/injure/threaten?
Y
N
Does the victim believe she/he may have been drugged?
Y
N
If yes, detail in narrative
Follow up needed
If yes or unsure, detail in narrative
Unsure
Did the victim voluntarily consume alcohol
Y
N
Did the victim voluntarily take other controlled
Y
N
within 24 hours of incident?
Follow up needed
substance within 96 hours of incident?
Follow up needed
If yes, detail in narrative
If yes, detail in narrative
Has sexual abuse by suspect been ongoing?
Y
N
Any other known or possible victims?
Y
N
If yes, how long?
Follow up needed
If yes, list names and contact information
Follow up needed
Victim Assistance Checklist
Victim’s Personal Safety Concerns Addressed
Sexual Assault Victim Rights and Services Information Provided
Victim Given Department Contact Information
Crime Victim’s Rights and Compensation Information Provided
International Association of Chiefs of Police
Page ____ of ____
Sexual Assault Supplemental Report Form
It is recommended that the Sexual Assault Supplemental Report be used in the reporting, recording and
investigation of all sexual assault incidents, for each and every incident reported
Supervisory review of all sexual assault cases is encouraged
This form is not intended for use when the victim is a minor
Agency
ORI
Incident #
Case #
Name of Person Who Contacted Police (optional on information reports)
Method Report Received
911 Call
Non-emergency number
Online
Other (describe)
Address of Person Who Contacted Police
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Relationship to Victim
Others Present with Victim During Interview
Location of Interview
Hospital
On Scene
At Department
Other (describe)
Dates
Date of Report (mm/dd/yyyy)
Time of Report
Date(s) of Incident (mm/dd/yyyy)
Time of Incident
From
To
Victim
Victim’s identifying or contact information may be exempt from disclosure under the Freedom of Information Act
and Crime Victim’s Rights Act or if this is a blind report.
Last Name
First Name
Middle Name
Any Aliases
Primary Language
Special Needs, Disability, Requests, etc.
Race/Ethnicity
Sex
Date of Birth (mm/dd/yyyy)
Height
Weight
M
F
Address
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Emergency Contact
Emergency Contact Telephone
Best Way to Safely Contact Victim
Victim Demeanor Observed at Time of Interview (select all that apply) Include detailed description in narrative
Other (describe)
Afraid/Fearful
Confused
Shaking/Trembling
Angry
Flat Affect
Tearful/Crying
Calm/Controlled
Nervous/Agitated
Withdrawn/Quiet/Flat Affect
Are there any injuries?
Y
N
Does the victim report pain?
Y
N
If yes, detail in narrative
Follow up needed
If yes, describe
Were weapons used to hurt/injure/threaten?
Y
N
Does the victim believe she/he may have been drugged?
Y
N
If yes, detail in narrative
Follow up needed
If yes or unsure, detail in narrative
Unsure
Did the victim voluntarily consume alcohol
Y
N
Did the victim voluntarily take other controlled
Y
N
within 24 hours of incident?
Follow up needed
substance within 96 hours of incident?
Follow up needed
If yes, detail in narrative
If yes, detail in narrative
Has sexual abuse by suspect been ongoing?
Y
N
Any other known or possible victims?
Y
N
If yes, how long?
Follow up needed
If yes, list names and contact information
Follow up needed
Victim Assistance Checklist
Victim’s Personal Safety Concerns Addressed
Sexual Assault Victim Rights and Services Information Provided
Victim Given Department Contact Information
Crime Victim’s Rights and Compensation Information Provided
International Association of Chiefs of Police
Page ____ of ____
Case #
Incident Information
Location of Interaction Before Assault(s) (detail in narrative)
Location(s) of Assault(s) (detail in narrative)
Locations Suspect Took Victim After the Assault(s) (detail in narrative)
Type of Coercion/Force/Fear Involved (select all that apply)
Disregarding the victims’ stated or
Victim was incapacitated (see below)
Threat of death
otherwise communicated lack of consent
Presence of weapon
Abduction
Verbal pressure/coercion
Stalking
Other (describe)
Position of authority (teacher, supervisor, boss, parent)
Physical restraint
Threat of physical force or violence
Physical force
Describe all types of coercion/force/fear involved. (Include detailed description in narrative)
Type of Assault (select all that apply)
Attempted
Completed
Rape (penile/vaginal penetration against the will, by force, threat, or intimidation)
Forced sodomy (penile/anal penetration against the will, by force, threat, or intimidation)
Forced oral-genital contact (oral copulation)
Forced sexual penetration with an object or finger
Sexual battery (forced touching of intimate parts, fondling, kissing, oral contact but not penetration)
Physical assault/battery
Strangulation
Other (describe)
Additional Crimes to be Investigated:
Victim Incapacitated or Incapable of Consenting or Communicating Unwillingness to Engage in Sexual Contact Due to: (select all that apply)
Age
Mental incapacity
Unconsciousness or sleep
Other (describe)
Alcohol
Physical incapacity
Drugs
Subordinate position
Initial Investigation
Victim Medical Treatment (select all that apply)
Where
By Whom
Date
First aid rendered
Medical exam
Forensic exam/rape kit
Admitted to hospital
Will seek own
Declined
Suspect Forensic Exam Conducted?
Y
N
Follow up needed
If yes, by whom?
Date
Photos
Taken By
Date Taken
Digital
Polaroid
35 mm
Video
Victim injuries
Suspect injuries
Crime scene(s)
Property damage
Evidence Collected (select all that apply)
By Whom
Location Stored
Analyzed
Y
N
Physical evidence (i.e. clothing, sheets, tissue) (list)
Y
N
Property damage (list)
Y
N
Weapons (list)
Victim Attached Suspect Attached
911 print out
Victim Attached Suspect Attached
Forensic exam report
Suspect polygraph
Toxicology report
Pretext phone call
Follow up needed, specify
International Association of Chiefs of Police
Page ____ of ____
Case # ______________________
Suspect
Photocopy and complete the following information for each suspect on a separate page and attach to the report.
Last Name (Suspect #
)
No. of Suspects
First Name
Middle Name
Aliases
Height
Weight
Hair Color
Eye Color
Race/Ethnicity
Sex
Date of Birth (mm/dd/yyyy)
Social Security No.
Driver’s License No./State
M
F
Address
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Primary Language (if not English)
Suspect’s Defining Characteristics (i.e. tattoos, scars, physical disabilities, etc.)
Suspect on Scene Y
N
Suspect Arrested Y
N
If Yes, Arrest Number
Suspect Conduct Prior to Incident (select all that apply)
Include detailed description as gathered from interviews of suspect, victim, and associated persons in narrative
Grooming (i.e. targeting vulnerability, testing boundaries, building trust)
Monitoring victim (tracking patterns of conduct)
Electronic contact (i.e. internet, text messaging)
Providing alcohol/controlled substances
Isolating victim
Other (describe)
Suspect Demeanor as Observed at Time of Interview
Relationship to Victim (select all that apply)
(select all that apply) Include detailed description in narrative
Recent acquaintance
Domestic partner
Parent of victim
Angry
Nervous/Agitated
Casual acquaintance of victim
Married
Relative of victim
Apologetic
Threatening
Friend (non-romantic)
Legally separated
Position of authority
Belligerent
Tearful/Crying
Internet relationship
Divorced
Co-worker
Calm/controlled
Withdrawn/Quiet/Flat Affect
Planned first meeting/date
Father of children
Stranger
Confused
Other (describe)
Intimate partner/dating
Cohabitating
Other (describe)
Former intimate partner/dating
Neighbor
Did the Suspect Consume Alcohol Within 24 Hours
Did the Suspect Take Controlled Substances Within
Visible Suspect Injuries?
Y
N
Prior to Incident?
Y
N
96 Hours Prior to Incident?
Y
N
If yes, detail in narrative
If yes, detail in narrative
Follow up needed
If yes, detail in narrative
Follow up needed
Suspect History
Date(s)
Type(s)
Arrest record
Y
N
Prior sexual assault offenses
Y
N
Prior use of weapons in a sex related offense
Y
N
Currently on probation
Y
N
Currently on parole
Y
N
Subject of protection order(s)
Y
N
Associated Persons
Photocopy and complete the following information for each witness on a separate page and attach to the report.
Last Name (Witness #
)
First Name
Middle Name
Aliases
Height
Weight
Hair Color
Eye Color
Race/Ethnicity
Sex
Date of Birth (mm/dd/yyyy)
Social Security No.
Driver’s License No./State
M
F
Address
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Relationship to Victim (see above categories)
Relationship to Suspect (see above categories)
Aware of Incident Y
N
Contact with Victim Prior to Incident Y
N
Contact with Suspect Prior to Incident Y
N
If yes, detail in narrative
If yes, detail in narrative
Present During Incident Y
N
If yes, detail in narrative
Contact with Victim After the Incident Y
N
If yes, detail in narrative
Did Victim Disclose Y
N
Contact with Suspect After the Incident Y
N
Did Suspect Disclose Y
N
If yes, detail in narrative
If yes, detail in narrative
If yes, detail in narrative
International Association of Chiefs of Police
Page ____ of ____
Case #
Interview History
Date(s)
Time
Location
Officer Initials
Victim
Suspect(s)
Associated Person(s)
Case Review Checklist
Select all that apply
Contacts Initiated by Police
Contacts Initiated by Victim
Follow-up photos taken of the victim’s injuries
(select all that apply)
(select all that apply)
(mm/dd/yyyy)
Community-based advocate
Community-based advocate
Available witness(es) interviewed
Medical
Dept./Victim/Witness advocate
Witness(es) provided a written statement
Mental health
Language translation
Unable to contact or interview the following person(s)
Other
Medical
Mental health
Probation/Parole
Prosecutor
Case referred to the prosecutor’s office
Other agency
(mm/dd/yyyy)
Evidence Follow-Up (select all that apply)
Victim Attached Suspect Attached
Victim Attached Suspect Attached
Toxicology results
Forensic exam results
Other
DNA results
Officer Printed Name
Rank
Badge Number
Officer Signature
Date (mm/dd/yyyy)
Investigator Printed Name
Rank
Badge Number
Investigator Signature
Date (mm/dd/yyyy)
Supervisor Printed Name
Rank
Badge Number
Supervisor Signature
Date (mm/dd/yyyy)
This project was supported by grant no. 2005-WT-AX-K077 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions,
findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the
Department of Justice, Office on Violence Against Women.
International Association of Chiefs of Police
Page ____ of ____
Case # ________________
Officer Narrative
(See next page)
Narrative Report Checklist
Describe and Document:
How case was received
Observations on approach—document what you saw,
heard, etc.
Spontaneous statements and demeanor at
time of statement
Victim
Victim during transport
Suspect
Suspect during transport and booking
Injuries of all parties
Type and extent
How the injuries occurred
Interview and provide detailed account of incident
Victim
Suspect
Witness(es), esp. first disclosure
Medical personnel
Drugs/alcohol used/involved
Weapons used/involved
Coercion, force, fear
Crime scene and physical evidence
Actions taken (i.e. evidence collected, arrest decision,
exams, follow up photographs and interviews)
Documents included with report (search/arrest
warrants, affidavits, subpoenas, 911 print-out, pretext
phone call synopsis, transcripts, crime lab reports,
victim/suspect forensic exam reports, photos, etc.)
Officer Printed Name
Rank
Badge Number
Officer Signature
Date (mm/dd/yyyy)
International Association of Chiefs of Police
Page ____ of ____

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