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? _________________________________________________________________

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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? _________________________________________
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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? _________________________

___________________________________________________________________________________