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close this bookClinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR) - WHO - OMS, 2001, 46 p.)
View the document(introduction...)
View the documentPreface
View the documentAcknowledgements
View the documentAbbreviations and acronyms used in this guide
View the documentIntroduction
View the documentSTEP 1 - Making preparations to offer medical care to rape survivors
View the documentSTEP 2 - Preparing the survivor for the examination
View the documentSTEP 3 - Taking the history
View the documentSTEP 4 - Collecting forensic evidence
View the documentSTEP 5 - Performing the physical and genital examination
View the documentSTEP 6 - Prescribing treatments
View the documentSTEP 7 - Counselling the survivor
View the documentSTEP 8 - Follow-up care of the survivor
View the documentAnnex 1 · Information needed to develop a local protocol
View the documentAnnex 2 · Sample consent form
View the documentAnnex 3 · Sample history and examination form
View the documentAnnex 4 · Pictograms
View the documentAnnex 5 · Protocols for treatment of STIs
View the documentAnnex 6 · Protocols for post-exposure prophylaxis of HIV infection
View the documentAnnex 7 · Protocols for emergency contraception
View the documentAnnex 8 · Minimum care for rape survivors in low-resource settings
View the documentAnnex 9 · Additional resource materials

Annex 2 · Sample consent form


Name of facility _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Note to the health worker: Read the entire form to the survivor, explaining that she can choose any (or none) of the items listed. Obtain a signature, or a thumb print with signature of a witness.

I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , (print name of survivor)

authorize the above_named health facility to perform the following (tick the appropriate boxes):


Yes

No

Conduct a medical examination, including pelvic examination

Collect evidence, such as body fluid samples, collection of clothing, hair combings, scrapings or cuttings of fingernails, blood sample, and photographs

Provide evidence and medical information to the police and/or courts concerning my case; this information will be limited to the results of this examination and any relevant follow_up care provided.

Signature:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Witness: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _