Consent to testing form - Department of Health Home
Commonwealth of PennsylvaniaSexual Assault Evidence Collection KitConsent for TestingThis form may be used by a law enforcement agency to obtain consent to test a sexual assault kit when consent was not granted by a victim at the time of kit collection. This form is not intended for use by healthcare facilities at the time of the medical-forensic exam. A law enforcement agency may also develop their own form for this purpose. Incident Number: _______________Date of Exam/Evidence Collection: _________________I, _____________________________________________, do hereby grant consent for laboratory testing and analysis of this sexual assault evidence collection kit.______________________________________________________________________________Victim’s Signature/Representative’s Signature______________________________________________________________________________Date of Consent______________________________________________________________________________Law Enforcement SignatureSecurely attach form to outside of kit. ................
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