QUESTIONS TO ASK TO VICTIMS OF A SEXUAL ASSAULT
aTTACHMENT H
CALIFORNIA DCR PRISON RAPE ELIMINATION POLICY
POST-SEXUAL ASSAULT INFORMATION
|IR#/VICTIM’S NAME & CDC # |Interviewing Staff |Date of Interview |
Did you…
➢ Bathe/shower/wash YES NO
➢ Brush teeth YES NO
➢ Use mouthwash/gargle YES NO
➢ Eat YES NO
➢ Drink YES NO
➢ Urinate YES NO
➢ Have a bowel movement YES NO
➢ Change your clothes YES NO
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 NO
➢ Finger YES NO
➢ Object YES NO
Describe the object used: ______________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
How many times?_____________________________________________________________________
How long did it last?___________________________________________________________________
Were you threatened? YES NO
If yes, describe. ______________________________________________________________________
Were you forced? YES NO Did he/she help you? YES NO
Were you physically harmed in any other way? YES NO
If yes, describe. ______________________________________________________________________
Did he/she touch or fondle you anywhere else? YES NO
If yes, describe. ______________________________________________________________________
Did he/she use any type of lubrication? YES NO If yes, describe. ______________________________________________________________________
Where was it applied? _________________________________________________________________
Was he/she wearing any clothes? If yes, describe. YES NO ___________________________________________________________________________________
What were you wearing? _______________________________________________________________
___________________________________________________________________________________
Did you keep your clothes on? YES NO If no, why? __________________________________________________________________________
Were there any distinguishable marks on his/her body? YES NO If yes, describe where and location: ______________________________________________________
Were there any distinguishable marks on his/her genital area? YES NO If yes, describe where and location: ______________________________________________________
➢ Did you see any pubic hair? YES NO
➢ Is it the same color as the hair on his/her head? YES NO
➢ Was he circumcised? YES NO
➢ Was his penis erect when you saw it? YES NO
Did he ejaculate? YES NO
If yes, where? _______________________________________________________________________
Did you ejaculate? YES NO
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 NO If yes, what? _________________________________________________________________________
Did you have anything to drink (inmate manufactured alcohol) or take any medication prior to the assault? YES NO
If yes, what?_________________________________________________________________________
What happened after the assault? ________________________________________________________
Did you “clean up” afterwards? YES NO 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 NO If yes, by whom, where, etc.? ___________________________________________________________
Have you ever engaged sexual activity with another individual of the same sex before? YES NO
Did you tell anyone else about this? YES NO If yes, who? _________________________________________________________________________
If longer than seventy-two hours (72), why did you wait to tell someone? _________________________
___________________________________________________________________________________
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