A5. Infrastructure for Justice System Response During the Exam Process
This section discusses elements essential to facilitate an effective initial response by the justice system to prepubescent child sexual abuse via child protective services and/or law enforcement agencies, focusing on multidisciplinary coordination during and related to the exam process.
Mandatory reporting statutes in a jurisdiction identify individuals—certain professionals and community members, and sometimes, all citizens—who are required to report suspicions of child sexual abuse, physical abuse, and neglect to legal authorities. That report typically triggers protective and investigative responses and can be a tool to facilitate medical forensic care as well as support for children and their families.
A5b. Confidentiality and Release of Information
Statutes and policies addressing confidentiality of child-responder communications in child sexual abuse cases and related records (including those from the medical forensic examination) typically allow information sharing among specified protective and investigating agencies so that case decisions are as informed as possible.
A5c. Evidentiary Kits and Forms
Standardized evidentiary kits and forms are typically used during the medical forensic examination in a jurisdiction to (1) make forensic evidence collection practices consistent across the community; (2) create a record of the medical history and exam findings; and (3) maintain the chain of custody of forensic evidence and information that will be included in the kit.
A5d. Timing of Evidence Collection
Forensic evidence collection in a particular case depends on timing and case circumstances. In addition to jurisdictional time frames for forensic evidence collection (e.g., within a certain number of hours or days since the sexual abuse), case circumstances may indicate a need for acute medical forensic care and forensic evidence collection.
A5e. Evidentiary Integrity
Maintaining the integrity of forensic evidence increases the likelihood it will be admissible if the case goes to trial. Jurisdictions should have policies in place regarding drying, packaging, labeling, sealing, and security of forensic evidence, as well as transfer of forensic evidence from exam facilities to law enforcement agencies.
A5f. Payment Issues
Jurisdictions investigating these cases have an obligation to cover all forensic costs associated with the medical forensic examination (recognizing that what jurisdictions consider to be forensic expenses can vary). Children and their families should not be obligated to pay for forensic costs, nor should exam facilities bill them for forensic expenses. Children and caregivers/families should be advised of their specific responsibilities regarding coverage of expenses related to medical forensic examination as well as any financial assistance available to help with these expenses, such as crime victims’ compensation. Jurisdictional reimbursement practices for examiners conducting the examinations and for the exam facilities should be fair and equitable.
These recommendations are for communities and responders related to mandatory reporting of sexual abuse involving prepubescent children.
Develop community-wide public awareness initiatives on mandatory reporting. Professionals who interact with children and families, as well as citizens in general, need education regarding mandatory reporting laws and policies in their communities related to child sexual abuse. The same type of constituent education is necessary in institutional settings and for tribal communities and military installations that have their own mandatory reporting requirements. In these settings, there is a need to explain if and how reporting and response to child sexual abuse is coordinated with agencies in the surrounding/another jurisdiction. Given that children who are abused often do not or cannot advocate for themselves, community professionals and citizens represent the front line in safeguarding their interests and connecting them with entities that can protect and help them.
Make sure that professionals and agencies/facilities involved in the community response to prepubescent child sexual abuse are aware of reporting requirements and what happens in a case once a report is made. They should know if they are a mandated reporter under jurisdictional laws, under what circumstances to report, the type of information to report, to whom they should report, the reporting procedures, and the timelines for making a report. They may need to be aware of reporting laws and procedures in more than one jurisdiction (e.g., for those who serve tribal communities, they should know applicable tribal, federal, and state laws and procedures for reporting). See below for a brief overview of child abuse and neglect reporting practices in the United States, which are inclusive of child sexual abuse.
General Information on Child Abuse and Neglect Reporting Practices
Requirement to report—
· States, the District of Columbia, and territories (Child Welfare Information Gateway, 2014b): All require certain persons to report suspected child abuse and neglect to an appropriate agency or agencies, such as child protective services, a law enforcement agency, and/or a state toll-free child abuse reporting hotline. Mandatory reporters vary across jurisdictions, but typically include individuals who have frequent contact with children: e.g., social workers, school personnel; physicians, nurses, and other health-care workers; counselors, therapists, and other mental health professionals; child care providers; medical examiners or coroners; law enforcement officers; and multiple other persons and entities. Some jurisdictions require any person who suspects child abuse or neglect to report. In all states, the District of Columbia, and territories, any person is permitted to report. Voluntary reporters of abuse are also referred to as permissive reporters.
· Tribal communities: Federal laws (Public Law 101-630, codified in 25 U.S.C. § 3203 and 18 U.S.C. § 1169, and Public Law 101-647, codified in 42 U.S.C. § 13031 and 18 U.S.C. § 2258) require certain professionals in the health care, mental health, education, child care, and law enforcement fields who work with children in Indian Country, as well as on federal lands or in federally operated (or contracted) facilities, to report suspected child abuse and neglect. Some tribes, particularly those in Public Law 280 jurisdictions, may also be required to follow state reporting laws and procedures. Tribes, as sovereigns, may enact their own codes and laws that include reporting requirements for professionals who may come into contact with children. In addition, certain professionals may have licensing standards that require the reporting of suspected child abuse or neglect. All mandatory reporters in the case of child abuse and neglect that occurs in tribal communities should be directed to report to the appropriate local law enforcement agency or child protection services/social services within the time frame required by statute.
· Military installations: Military service installations’ family advocacy programs receive reports of child abuse and neglect for families of service members assigned to that installation. Certain Department of Defense personnel are considered mandatory reporters, including commanders and military police, military health care staff, child and youth staff, and school personnel. Family advocacy program reports are shared with military police and appropriate civilian agencies (reports can also be made directly to them).
· Institutional settings (such as college campuses or correctional facilities) may have internal child abuse and neglect reporting requirements.
Penalties for not reporting: Most jurisdictions impose criminal penalties on mandatory reporters who knowingly or willfully fail to make a report of, or prevent a subordinate from reporting, suspected child abuse or neglect.
Immunity from liability: Jurisdictions generally provide immunity from liability for persons who in good faith report suspected child abuse or neglect under reporting laws.
When to report: The circumstances under which a mandatory reporter must make a report vary, depending on the jurisdiction or institutional setting. In many jurisdictions, a report is required when the reporter, in her/his official capacity, reasonably suspects that a child has been abused or neglected.
Reporting procedures: Reporting procedures vary across jurisdictions and institutional settings regarding timing of an oral report, need for and timing of a written report, and information to provide the receiving agency. Often, the following information is sought: contact and identifying information for the child and the suspected perpetrator, including the nature of the relationship between child and perpetrator; the reporter’s contact information; and the reason for the concern.
Initial response to a mandatory report: Laws and/or policies in each jurisdiction and institutional setting should specify procedures for the initial response required by agencies receiving child abuse and neglect reports. If a child protective service agency in a jurisdiction receives a report, it generally has a process to screen the case to determine whether acts meet jurisdictional statutory definitions of child abuse or neglect. Child protective service agencies generally have the responsibility of responding to cases in which child abuse or neglect is caused by one or more persons who have caregiver responsibilities. They also usually have jurisdiction-specific procedures for cross-reporting cases to law enforcement agencies for potential criminal investigation. Investigations may be conducted by the child protective service agency, a law enforcement agency, or cooperatively by both agencies. Institutional settings may have specific initial response procedures.
Sharing report information: Most jurisdictions and institutional settings with child abuse reporting systems require some or all agencies that receive mandatory reports to share report information among entities conducting the investigation or assessing child protective needs. Typically, child protective service agency reports are shared among social services agencies, law enforcement agencies, and prosecutors’ offices. Child sexual abuse multidisciplinary response teams should ensure that mechanisms are in place to facilitate information sharing in individual cases among agencies in their jurisdiction involved in investigations. Agencies/facilities and teams should consider applicable privacy laws when creating information sharing policies. (See A5b. Confidentiality and Release of Information)
Stress that a SUSPICION of child sexual abuse alone IS SUFFICIENT to trigger a mandatory report. Child abuse reporting systems function to ensure children’s safety if any question exists that abuse or neglect has occurred.  Suspicion of sexual abuse may be based on a disclosure by the child or another person, or observations of a pattern of indicators associated with sexual abuse.
It is not a mandatory reporter’s role to verify that abuse has occurred. A mandatory reporter should not make any assumptions about legal charges or actions that may be taken in response to a report. Mandatory reporters must not fail to report because they believe that the victim or another responder or third party has already reported or will make a report (e.g., primary care providers may inaccurately think that if they refer the child to a pediatric examiner, they do not need to report themselves).
Understand how mandatory reporting and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) confidentiality provisions interact. The HIPAA privacy rule and its implementing regulations (45 CFR Part 160 and Subparts A and E of Part 164), established national standards for the protection of certain individually identifiable health information created or held by health plans, certain health care providers, and health clearinghouses. Health care facilities and medical personnel involved in caring for prepubescent child sexual abuse victims should be instructed that (1) mandated child abuse and neglect reporting laws fit under exceptions to HIPAA and require the release of information as allowable by applicable laws when reporting is triggered (Gudeman & Monasterio, 2014); and 2) they may disclose only information that is necessary to satisfy a jurisdiction’s mandatory reporting requirements.
Ensure that mandatory reporting procedures are consistent with the confidentiality provisions of the Violence Against Women Act (VAWA). This provision prevents VAWA grantees that provide victim services from releasing personally identifying information about a victim served without the victim’s consent. However, it includes exceptions in situations where release is mandated by law, such as mandatory reporting of child abuse. In such cases, the grantee is required to notify the victim and take steps necessary to protect the privacy and safety of the persons affected by the release. VAWA grantees who are not mandated reporters under their jurisdictional laws may only report abuse with victim consent.
Ensure that responders know their agency/facility procedures and jurisdictional requirements for making a mandatory report of child sexual abuse. An organization may have internal procedures related to reporting to comply with applicable reporting laws. In addition to jurisdictional requirements of individual responders, some entities may require their staff to share child abuse suspicions with a centralized administrator, who then makes mandated reports on behalf of the entity (Gudeman & Monasterio, 2014). In most jurisdictions, however, reporting to a superior in an organization does not negate the obligation of the person with first-hand knowledge to report. Also, waiting for a centralized administrator to report is not appropriate when a child is in imminent danger. Responding agencies should train their staff on how to report so they do not need to seek out a superior or wait for a centralized administrator in order to make a report (even if they are required to involve their superior/centralized administrator at some point in the process).
Ensure that communities and multidisciplinary response teams facilitate coordination of response to reports of child sexual abuse among child protective services, law enforcement agencies, and any other agency officially designated to receive or respond to reports. Specifically they should: (1) Educate mandatory reporters to report to the appropriate entity, but also streamline the initial response to encourage and facilitate timely reporting. No matter which agency receives a report, it should be acted upon in an appropriate, prompt manner. (2) Educate reporters regarding what type of response to expect from child protective services, law enforcement agencies, or other receiving agency following a report of sexual abuse; how these agencies respond differently given case circumstances; and if, when, and how they coordinate their actions in a case. (3) Ensure that agencies receiving reports facilitate immediate coordinated interventions in situations when there is concern about a child’s imminent safety. To this end, the method to report should not be via an answering machine—a live intake person is recommended. (4) Publicize among responders to child sexual abuse and other mandatory reporters in the community or institutional setting appropriate contact persons in the child protective service agency and law enforcement agencies in case of reporting questions or concerns.
Encourage multidisciplinary response teams, as well as individual agencies/facilities that respond to child sexual abuse, to develop policies, tools, resources, and training related to reporting. For example, they can (drawn in part from Gudeman & Monasterio, 2014):
· Develop policies to clarify staff reporting roles. Also, identify staff from local child protective services and law enforcement agencies who can be resources for advice on complex questions related to reporting.
· Train staff. For example, educate them on what is/is not reportable, procedures and required time frames for reporting, how the jurisdiction or institutional setting responds to reports, communicating with children and caregivers on reporting requirements, trauma-informed reporting practices, and other related issues.
· Create tools to facilitate the reporting process. For example, standardized reporting forms can allow consistent information about suspected abuse to be provided to receiving agencies. Algorithms and checklists can help explain reporting obligations, in what situations a report is required, which agencies should receive the report and their subsequent roles, what information is released to which agencies, and coordination among agencies that will occur in response to the report. If the jurisdiction does not require a written report in addition to an oral report, reporting agencies may wish to develop a form to document oral for reference purposes. If there is a separate reporting mechanism within the facility, be sure to include that component of the reporting process in any tools or educational information given to staff. If feasible, obtain a signature of receipt of a report from the receiving agency. Also, consider creating an acknowledgement form for caregivers to sign and return to the reporting agency for its records (that a report was sent, not for consent to report as that is not necessary). Such tools should be created in consultation with an entity’s legal counsel.
· Regularly review (e.g., annually) policies and training requirements/programs and update accordingly.
Identify, in advance, situations where reporting practices may be more complex than usual due to jurisdictional issues. The multidisciplinary response team can collaborate to determine how to approach complexities in reporting and clarify practices that will be employed. For example: if the child sexual abuse occurred in a tribal community where more than one jurisdiction may be involved; if the child is a dependent of an active duty soldier living on a military installation and the abuse occurred both on the installation and off; or if a child was sexually abused in both the United States and another country. Teams can explore different situations to determine who receives the report and how to forward it to the correct responders (local, state, tribal, federal, military, neighboring country, etc.).
Consider what actions by the responding agencies/facilities and the multidisciplinary response team could increase reporting of child sexual abuse in the community. For example:
· Plan to survey the community to learn more about related reporting trends;
· Seek input from community members and professionals on ways to improve upon child sexual abuse identification and response efforts, to increase the positive impact of reporting for children and families, and to reduce negative consequences;
· Identify measures the community can employ to help children and families feel safer in seeking help—e.g., provide individualized safety planning assistance and information about interventions and services to address specific needs (see B11. Discharge Planning and Follow-Up Care);
· Identify community outreach, education, and services that might be helpful to specific populations;
· Explore what the community can do to promote reporting by professionals, citizens, and families when they suspect child sexual abuse, including of nonverbal children and children with disabilities; and
· Address the prevention of child sexual abuse.
These recommendations are for communities, responding agencies/facilities, and individual responders regarding confidentiality in prepubescent child sexual abuse cases and release of medical forensic exam information for investigative purposes.
Ensure that jurisdictional and institutional policies, response team protocols, and medical forensic exam procedures address confidentiality in sexual abuse cases involving prepubescent children and release of exam information for investigative purposes (including written and photo-documentation). It is useful to have mechanisms to track information shared from the medical forensic examination in individual investigations. Information to track includes but is not limited to: mandatory reports, to whom case information has been released, and communication related to case investigation.
Ensure that responders’ are adequately trained to have a clear understanding of relevant confidentiality issues in cases of sexual abuse of prepubescent children.
Key Points: Confidentiality and Information Sharing
· Records required by child sexual abuse reporting laws should be maintained as confidential and released only as permitted by applicable laws and policies of the jurisdiction. Many state, territorial, federal, and tribal statutes specify who may access the records and under what circumstances. Responders should be familiar with applicable laws and policies to provide accurate information to children and caregivers as appropriate. They should also understand applicable laws regarding disclosure of the reporter’s identity.
· Most jurisdictions require some or all agencies that receive mandatory reports to share report information among relevant agencies to appropriately respond to allegations —typically, child protective service reports are shared among social services agencies, law enforcement agencies, and prosecutors’ offices (Child Welfare Information Gateway, 2013a). Jurisdictional law may permit this data to be shared among members of the multidisciplinary team that responds to child abuse (see National District Attorneys Association, 2015).
· As discussed in A4a. Reporting, the duty of health care providers to report suspected child abuse is an exception to HIPAA privacy requirements, as is ongoing communication on these cases with those involved in the investigation. In addition to the mandatory report, medical records in child sexual abuse cases are typically requested by investigating entities. Records from the medical forensic examination of prepubescent children—with the exception of photo-documentation—should be shared with investigative entities as per applicable laws and policies of the jurisdiction. (Photo-documentation can be released to investigative agencies with a subpoena and preferably with interpretive consultation withthe examiner or an appropriatechild sexual abuse specialist. (See B6. Photo-Documentation) Records from follow-up medical forensic care will also likely become part of the investigative record. Because HIPAA allows for the release of children’s medical records to those authorized to respond to mandatory reports of child abuse and neglect, parental/guardian signature for the release is not legally required . Health care providers can use an informed consent process to ensure that information is shared in an appropriate and ethical manner (See B1. Consent for Care) Keeping a HIPAA disclosure log is important to account for disclosures of protected health information. The facility also should request a receipt from investigative agencies acknowledging what records were received.
· All jurisdictions have confidentiality provisions to protect abuse and neglect records from public scrutiny (Child Welfare Information Gateway, 2013b). Additionally, many jurisdictions have laws imposing confidentiality restrictions on child abuse multidisciplinary response teams (see National District Attorneys Association, 2015). To that end, exam facilities, investigative agencies, and multidisciplinary response teams should have policies and written agreements in place that maintain records in a child sexual abuse case as confidential outside of those entities, to the extent allowable by law. These policies and agreements should not only apply to case records, but also to documentation from case reviews and case-related communication among responding entities involved in an investigation. For example, some child abuse multidisciplinary teams require members to sign a form agreeing to keep information discussed confidential at every team meeting. (See A3. Coordinated Team Approach) Agencies/facilities that hold records must also consider how to securely store paper and electronic files, photographic images, and other case documentation, and limit access to those records. (See B4. Written Documentation and B6. Photo-Documentation)
Instruct pediatric examiners and other health care providers on what to communicate to children and caregivers pertinent to confidentiality of the child’s medical record. Take into consideration children’s development level as well as the linguistic capacity of children and caregivers.
· Begin interactions with children by providing clear information on confidentiality, explaining that confidentiality of health care services may be limited in cases involving child sexual abuse. Concepts related to confidentiality and child abuse reporting can be confusing. Addressing these issues at the start of a visit and using examples to explain concepts can help to build the rapport needed to provide good care.
· Explain to children and caregivers that information gathered during the examination and follow-up medical forensic care will be included in the medical record and shared with investigative entities. Discuss who else might legally have access to the information based on jurisdictional statutes and policies. Children and caregivers may wrongly assume that medical records from the examination are protected health information and may be unaware that privacy laws may be overridden in cases of prepubescent child sexual abuse. Also, inform children that their caregivers will likely have access to the record at the close of the investigation (unless the caregivers perpetrated the abuse, are in collusion with the perpetrator, or are otherwise abusive to the child).
· Note that, due to mandatory reporting laws, parent/guardian consent is not required to release information to investigative agencies or others who are allowed access by applicable laws and policies. This is an exception to HIPAA. Release of records for an investigation of child sexual abuse should not be delayed for parental signatures.
· If developmentally appropriate, explain to children that the accompanying caregiver will be notified that a report of sexual abuse has been or will be made. (See A5a. Reporting) However, this notification should not occur if it is suspected that the caregiver perpetrated the abuse, is in collusion with the perpetrator, or is otherwise abusive to the child. Examiners can discuss with law enforcement and/or child protective service agencies, as well as their facility legal counsel, how to navigate such a situation.
· Explain to caregivers that, although they have access to the child’s medical information from the examination, results from the evidentiary material collected will not be immediately available to them. Investigators can review with caregivers when this information will likely be available.
Clarify questions about confidentiality of victim advocates. One way to protect a child’s confidentiality during the exam process is to limit individuals present with the child during the history taking and the examination. However, as discussed in this protocol, children and caregivers can benefit from the presence of victim advocates during the exam process. Victim advocates, if available in a community, can offer a range of supportive services, including crisis intervention, advocacy, and referral to other resources.
HIPAA permits hospitals and other health care providers to alert an advocacy organization of the presence of a child victim of sexual abuse and caregiver at the health care facility, without giving any identifying information about the child or caregiver. Once the advocate is present at the facility, if the child and/or caregiver is informed in advance and agrees, then HIPAA permits facility staff to introduce the advocate to the child and/or caregiver. The advocate can then share information pertinent to her/his involvement during the examination and seek permission to provide services. 
Note that the mandatory reporting obligations of community-based victim advocates vary by jurisdiction. In some jurisdictions, community-based advocates are mandated reporters of child abuse. In others, they are not, and VAWA’s confidentiality provisions may limit their ability to make a report without the victim’s consent. For child victims, their families, and other responders to fully understand the level of confidentiality that advocates may offer, it is important to determine whether a jurisdiction’s law requires advocates to report child sexual abuse.
All multidisciplinary response team members should understand the benefits of advocate involvement on the response team—mainly, to ensure ongoing support for the child and family members and promote a collective team response that is child-focused, victim-centered, and trauma-informed. At the same time, they should be aware of and respect the scope and limitations of advocacy program information sharing policies.
These recommendations are for jurisdictions and entities involved in creating or customizing evidentiary kits and forms for sexual abuse medical forensic examinations of prepubescent children.
Use kits that meet or exceed minimum guidelines for contents. Many jurisdictions have developed kits for collection of forensic evidence from victims of sexual violence or purchase premade kits through commercial vendors. Kits may vary in type of samples collected, collection techniques, materials used for collection, terms used to describe categories of forensic evidence, and criteria for use. Despite variations, however, it is critical that every kit meets or exceeds the following minimum guidelines for contents.
Minimum Guidelines for Kit Contents
· Kit container: This container typically has a label with blanks for identifying information and documenting the chain of custody. Most items gathered during forensic evidence collection are placed in the container, after being dried, packaged, labeled, and sealed according to jurisdictional policy. Bags/containers are usually provided for more bulky items that will not fit into the container (e.g., clothing, bedding, or diapers). Some jurisdictions provide large paper bags to hold the container and additional evidence bags.
· Instruction sheet or checklist that guides examiners in: determining if the case meets criteria for kit use, documenting the examination, collecting forensic samples, and maintaining the chain of custody of forensic evidence. Instructions may also include tips for preparing and providing support for the child and caregiver prior to the examination, and ensuring no emotional harm to the child in the course of the examination.
· Forms, including: consent for the examination, medical history, exam documentation, and anatomically neutral body maps. Forms included should be designed to facilitate optimal forensic evidence collection, documentation, analysis, and examiner testimony.
· Materials for collecting and preserving the following forensic samples, according to jurisdictional policy:
o Clothing worn at the time of the abuse or immediately after, underwear/diapers, and foreign material dislodged from these items
o Foreign materials on the child (e.g., blood, dried secretions, fibers, loose hairs, vegetation, soil/debris, fingernail scrapings and/or cuttings, matted hair cuttings, and material dislodged from the mouth)
o Oral swabs
o Genital swabs
o Vaginal or penile swabs
o Anal/perianal swabs
o Additional body swabs
o Buccal swab for DNA analysis and comparison (alternatively, saliva sample or known blood)
See B8. Evidence Collection for more detail on how kit contents are used during the examination.
Ensure availability of materials, instructions, and forms for collecting toxicology samples. These items are typically separate from the jurisdictional forensic evidence collection kit. Investigative agencies should identify labs that have the capacity to analyze toxicology samples. Ensure that examiners  have the appropriate materials, instructions, and forms from those labs or those that meet lab specifications. (See B9. Sexual Abuse Facilitated by Alcohol and Drugs)
A single forensic evidence collection kit is sufficient for adult and children victims, provided it accommodates aspects specific to both populations. Although not required, a separate pediatric kit is strongly encouraged as oftentimes the health community may not otherwise see the urgency and necessity of engaging properly trained pediatric examiners and using medical forensic care tailored to the needs of children who may have been sexually abused.
To accommodate cases involving prepubescent children, a kit should include instructions and forms for forensic evidence collection and documentation that are specific to these victims, and differentiate between procedures in acute versus nonacute examinations. In particular, while forensic specimens may or may not be collected during an examination of a prepubescent child, depending in part on whether the examination is acute or nonacute, documentation from the medical history and exam findings can be invaluable to an investigation and should always be completed.
Crime lab personnel who analyze forensic evidence kits should be instructed to not consider a kit invalid if certain forensic evidence was not collected. Due to the nature and circumstance of a sexual victimization, the examiner may modify or omit certain forensic samples. If a jurisdiction employs different documentation forms for the nonacute examination, documentation should not be considered invalid if acute exam forms are mistakenly used. Examiners should be encouraged to establish and maintain working relationships with crime lab personnel serving their jurisdictions to ensure that forensic specimen collection for the kit comports with how the crime lab currently tests forensic evidence and respond to any questions.
The jurisdiction should work with the multidisciplinary response team to standardize the jurisdictional evidentiary kit and documentation forms for prepubescent child sexual abuse cases. A designated entity, whether the team or a specific agency or agencies, should be responsible for oversight of the standardization process, as well as kit and form development and distribution.  It is important to:
· Ensure that exam facilities in the community are sufficiently supplied with kits and forms;
· If the nonacute exam documentation forms are the same as those used in the forensic evidence collection kit, ensure they are available separately from the kit so that examiners need not open a kit to access these forms;
· If different documentation forms are used for acute examinations versus nonacute examinations, ensure that all examiners understand the purpose of and have access to both forms;
· Make all exam documentation forms accessible electronically and formatted to be filled out electronically or downloaded to type in or write on by hand;
· Ensure that relevant entities (e.g., crime labs, toxicology labs, children’s protective service agencies, law enforcement agencies, exam facilities, children’s advocacy centers, and prosecutors’ offices) and professional organizations receive ongoing and updated training regarding changes in technology, scientific advances, and cutting-edge practice related to collecting forensic evidence from prepubescent children;
· Review/evaluate the kit and forms periodically (e.g., every 2 to 3 years), revising as needed for efficiency, current best practice, and usefulness; and
· Establish mechanisms to ensure that unused kits and forms at exam facilities are kept up-to-date and do not include expired materials.
These recommendations are for justice system agencies to maximize forensic evidence collection. See below for general considerations. However, it is important to follow jurisdictional policy
Promptly collect forensic samples as the likelihood of obtaining viable specimens decreases over time.
· Forensic evidence can be lost from the child’s body and clothing through numerous mechanisms (e.g., degradation of seminal fluid components can occur in body orifices, semen can drain from the vagina or wash from the mouth, sperm can lose motility, bodily fluids can wash away, and dried secretions and foreign materials can fall from the body and clothing) (California Office of Emergency Services, 2001).
· Limit loss of forensic evidence on the child’s body or clothing prior to the medical forensic examination without compromising the child’s comfort. For example, if a suspicion exists that alcohol or drugs contributed to the abuse and the child needs to urinate before arrival at the exam facility, instruct first responders to collect a urine sample. If a child is thirsty, the initial health care provider may be able to obtain oral swabs before other evidence is collected so that the child may obtain a drink.
Collect forensic samples within the prescribed jurisdictional time frame (which should be a minimum window of 72 hours since the sexual abuse). In addition, case circumstances and future research may indicate a need for an acute examination and forensic sample collection beyond that time frame. (See B3. Entry into the Health Care System)
· Indications for the collection of forensic samples should be considered on a case-by-case basis (e.g., unwashed clothing that the child wore during the abuse can be collected beyond 72 hours).
· Collection of internal vaginal and cervical swabs is not indicated for prepubescent children. Forensic samples are obtained from the external genitalia surfaces only, unless a medical necessity exists to use anesthesia.
· Keep up-to-date on the latest research and technological advances in DNA detection and analysis that may suggest changes in when to collect forensic samples from prepubescent children and best methods for analyzing evidence. Involve pediatric examiners and crime lab personnel in determining how any new information results in changes in practice.
Timely medical care and treatment for all victims of child sexual abuse is critical, whether or not forensic samples are collected. Health care providers to whom the child initially presents should determine the urgency of medical forensic care needed and if forensic samples might be available, based on jurisdictional policy. Law enforcement and child protective service representatives should defer to health care providers to determine the medical forensic care needed and the availability of samples. Health care providers should consult with pediatric examiners on individual cases as needed. (See B3. Entry into the Health Care System)
· The need for emergent treatment of injuries always supersedes forensic evidence collection.
· Despite whether forensic evidence on the child’s body or clothing is potentially available, the child should be examined, a medical history taken, related treatment provided, and exam findings documented. Information helpful to the investigation may be obtained from the history, exam findings, and the child’s medical record.
· A child should never be forced to undergo the medical forensic examination and/or have forensic evidence collected. (See B1. Consent for Care)
These recommendations are for examiners and law enforcement agencies regarding forensic evidence integrity.
Maintaining the integrity of forensic evidence during the exam process increases the likelihood that the evidence collected will be admissible if the case proceeds to trial. Pediatric examiners must handle forensic specimens properly from collection until turning them over to law enforcement. Transfer procedures are needed by law enforcement to ensure maximum preservation of forensic evidence collected until its analysis. 
For Pediatric Examiners
Follow jurisdictional policies for drying, packaging, labeling, sealing, and storing forensic specimens, as well as maintaining the chain of custody of forensic evidence until released to the appropriate law enforcement agency. Contact law enforcement, prosecution, and/or the crime lab with any questions. Proper management of forensic evidence is critical to avoid loss or alteration of evidence and to potentiate its admissibility during a trial. See section B8. Evidence Collection for more information on specific steps in collecting evidence.
General Considerations for Forensic Evidence Integrity
Dry forensic specimens unless otherwise indicated
· Follow proper drying procedures for different types of specimens—proper drying and packaging prevents growth of mold and bacteria that can destroy forensic samples.
· Air-dry wet forensic evidence at room temperature in a clean environment and manner that prevents contamination. Note that the ever-increasing sensitivity of DNA analysis creates a greater chance that accidental contamination and dilution by foreign DNA may be detected.
· A swab dryer or other drying device may be used to facilitate drying.
Package forensic specimens appropriately
· Follow proper packaging procedures for different types of specimens.
· After drying specimens, package each different type in paper envelopes.
· Package dry clothing evidence individually in paper bags.
· Follow proper procedures for packaging specimens that cannot be dried thoroughly at the exam facility (e.g., wet clothing, diapers, and condoms) to prevent leakage and contamination of other evidence. Wet evidence may be placed in plastic bags then dried later by the crime lab or designated storage facility and repackaged.
· Follow proper procedures for packaging liquid evidence (e.g., urine and drawn blood samples).
General Considerations for Forensic Evidence Integrity
Label forensic specimens accurately
· Discuss in advance with the crime lab the most accurate methods for labeling various types of forensic specimens collected for crime lab analysis.
· Label all specimens clearly, including name and date of birth of the child, the source of the specimen, date and time of collection, and examiner’s name or initials (plus any additional requirements, such as case number).
· Write on the specimen label any variations or modifications in the collection.
· Note any wet/moist items and whether they need to be air-dried. Communicate, upon release, the presence of any wet/moist specimen to law enforcement officials.
Establish and document the security and chain of custody of forensic specimens throughout the exam process
· Seal specimen packages to prevent tampering. However, do not lick envelopes.
· Document the examiner’s signature, date, and time across the seal.
· For forensic evidence to withstand judicial scrutiny, the chain of custody must be documented from the time the specimens are collected to their release to the investigating agency.
· Limit the number of people who handle any forensic evidence.
· Develop procedures to trigger law enforcement pick-up of forensic evidence.
· Know the appropriate law enforcement entity to contact for pick-up.
· Document the identity, date, and time of the law enforcement representative picking up the forensic evidence.
Store forensic specimens at the exam facility until released to law enforcement personnel
· Develop procedures to securely store forensic specimens in a locked location at the exam facility until released to law enforcement personnel. Jurisdictions may have policies on the length of time that forensic evidence kits may be stored at the exam facility and the time frame in which law enforcement must pick up the kit from the exam facility.
· In addition to storing dry specimens, exam facilities should have secure, limited access refrigeration for storage of wet items and liquid samples, preferably in a locked refrigerator. Some wet and liquid samples can also be frozen; however, blood cannot due to the risk of the glass tubes breaking. If a locked refrigerator is not immediately available, samples can be kept at room temperature for no longer than 24 hours. If blood is needed for other than medical or toxicological reasons, dried blood samples on blood collection cards are encouraged (and do not require refrigerated storage).
Follow jurisdictional policy for completing written documentation to be included in the evidentiary kit. In acute cases, jurisdictional exam report forms should be completed (noting reasons if one or more sections are incomplete), labeled, and included in the sealed kit. Note that the child’s medical record, including exam photo-documentation, should not be included in the kit. In nonacute examinations, there is no evidence collection kit. However, there may be jurisdictional nonacute exam report forms—if so, complete and provide to the proper agency/agencies according to jurisdictional policies. Otherwise, medical forensic examination documentation should be maintained, secured, and released per facility policy. (See B4. Written Documentation and B6. Photo-Documentation)
For Law Enforcement Agencies
Be familiar with procedures in prepubescent child sexual abuse cases related to transfer of forensic evidence from medical forensic exam facilities to a jurisdictional crime lab or designated law enforcement evidence storage. A few general considerations are offered below. However, follow jurisdictional policies.
General Forensic Evidence Transfer Considerations for Law Enforcement
Make sure transfer policies (from exam facilities to the crime lab and evidence storage) maximize preservation of forensic specimens and maintain the chain of custody
· Only a law enforcement official/duly authorized agent should transfer forensic evidence from the exam facility to the crime lab or other designated law enforcement storage site. Communicate with pediatric examiners and exam facilities regarding procedures to trigger a transfer. Note that, in some jurisdictions, the kit is mailed. In such instances, established procedures must be in place and followed to maximize preservation and maintain the chain of custody of forensic evidence.
· Avoid the potential degradation of forensic specimens by minimizing the transit time between the collection of forensic evidence and the storage of kits—this practice is particularly important with kits containing liquid and other wet specimens.
· The law enforcement official picking up the forensic evidence should be familiar with what items may be in the kit, confirm whether any evidence is wet or needs to be refrigerated, and ensure that the kit is properly sealed and marked.
· When forensic evidence is transported to the crime lab or other designated storage site, the law enforcement official should inform receiving personnel of any relevant information (e.g., the kit contains wet evidence that needs to be refrigerated).
· Jurisdictional procedures for transfer of forensic evidence must be in place, followed, and account for any challenges faced by law enforcement agencies in prompt pick-up of kits from the exam site, in storing evidence, or in otherwise maintaining forensic evidence integrity.
These recommendations are for communities regarding covering the costs associated with the sexual abuse medical forensic examination of prepubescent children.
Jurisdictions should explore all viable sources of funding for sexual abuse medical forensic examinations for prepubescent children. The goal is that children and their families are not charged for forensic evidence collection and have reliable sources of financial aid for related medical expenses AND that examiners and exam facilities are adequately reimbursed for their services in each case. 
Payment issues specific to children’s families:
· Children’s families should not incur expenses related to forensic evidence collection, even if exam facilities bill them for these costs. However, it is best practice for the payment to be handled without the families receiving bills. If families do receive such bills, they should be advised where to forward the bills (e.g., to a specified investigative agency or back to the health care facility) and how the bill will be handled so that they are not held responsible for payment. Prompt systemic assessment and improvement should also take place, to ensure that such mistakes do not continue to occur.
· Children’s families need to be advised of their responsibility for related exam expenses. Jurisdictions vary in what they cover as part of the medical forensic examination (e.g., most do not cover costs of treatment for injuries). If children’s health insurance is used to cover these costs, caregivers should understand their financial responsibility if insurance only partially covers the expense.
· When children’s families are billed by health care facilities, procedures should be in place to protect the family’s privacy in the billing process. Personnel in facility billing departments should be educated regarding appropriate billing practices and codes in these cases, as determined by facility policy. They should be instructed not to bill children’s families for costs that should be covered by the jurisdiction. A mechanism should be established for responders in conjunction with billing department personnel to assess whether a child’s health insurance should be billed in the case that the suspect perpetrator is the insured party. The child may face safety risks if the suspected perpetrator receives an explanation of benefits from her/his insurance company indicating that exam services were provided to the child.
· Children’s families need to be advised of the availability and eligibility criteria of financial assistance programs that help with exam expenses, such as state crime victim compensation programs. Families need to know if the crime victim compensation program covers both acute and nonacute examination costs for prepubescent children who are suspected of being sexually abused. Victim advocates typically can assist children’s caregivers in applying for compensation.
Payment practices related to exam reimbursement to pediatric examiners and exam facilities are complex and vary between jurisdictions. Unfortunately, with no one prescribed designated method of payment, many exam facilities piece together funding to provide pediatric exams. Jurisdictions need effective payment structures to ensure these examinations are available to all children who require them, free of all charges. Some issues to consider:
· Reimbursement practices for pediatric examiners conducting examinations and medical facilities where examinations are conducted should be equitable in all jurisdictions. Payment structures should take into consideration that pediatric examinations may differ from adult and adolescent examinations. In particular, since delayed reports are typical in child sexual abuse cases, there is forensic value to a non-acute examination. Eligibility for reimbursement in delayed reporting cases should be extended to retain exam findings and provide essential care to a child. Also, because, in some communities, specialty care programs conduct these examinations, an initial assessment to determine urgency of care may be performed at one facility that may precede the medical forensic care provided at another facility. In this case, both medical facilities should be reimbursed by the jurisdictions for services rendered, rather than just one or splitting reimbursement between the two. Funding sources should fairly reimburse examiners and exam facilities for their costs.
· At a minimum, the following costs of a sexual abuse medical forensic examination should be included as reimbursable by jurisdictions to examiners and exam facilities: the examination and forensic evidence collection, STD testing and treatment related to sexual abuse (including HIV testing and post-exposure prophylaxis), and related follow-up testing and medical examinations. There should be no circumstances in which the children’s families are billed because jurisdictions did not appropriately reimburse the facility or examiner.
· Jurisdictions should provide reimbursement for examinations performed at medically-based locations, including hospitals AND other facilities, such as children’s advocacy centers, health clinics, and other locations that offer medical services. The key is to have a trained pediatric examiner conduct the examination.
· Jurisdictions should authorize payment for the examination to the examiner and exam facility, based on clinical judgment that medical forensic care is needed, with payment linked to reporting of child sexual abuse by the provider. As mentioned earlier, health care providers, rather than investigating agencies, should determine the need for medical forensic care. Payment should not depend on the submission of a complete forensic evidence collection kit. In some prepubescent child cases, certain procedures are not applicable. In nonacute cases, only documentation forms may be completed.
· In the case of sexual abuse in tribal communities, a multi-jurisdictional effort may be necessary to collectively determine payment issues so that children’s families are not billed for forensic costs and options exist for financial aid to help cover the cost of the examination.
|Table of Contents||B. Exam Process|
 In this document, “territories” refer to those U.S. territories that are permanently inhabited: American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands.
 For state toll-free reporting numbers, see Child Welfare Information Gateway at www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspROL&rolType=custom&rs_id=5.
 See Child Welfare Information Gateway (2014a) for a discussion of how states have or have not addressed the issue of clergy as mandated reporters and clergy-penitent privilege within their reporting laws. At the time of this document’s publishing, a little more than half the states and Guam include clergy as mandated reporters of child abuse and neglect.
 Child Welfare Information Gateway (2014b) details who is required to report in a specific state or territory. See www.childwelfare.gov/pubPDFs/manda.pdf for a compilation. Alternatively, search for a specific state or territory statute at www.childwelfare.gov/topics/systemwide/laws-policies/state/.
 Note that other laws may impact voluntary reporting (e.g., VAWA confidentiality provisions as explained later in this chapter).
 Indian Country refers to: (a) all land within the limits of any Indian reservation under U.S. jurisdiction, notwithstanding the issuance of any patent, and, including rights-of-way running through the reservation, (b) all dependent Indian communities within the borders of the U.S. ,whether within the original or subsequently acquired territory thereof, and whether within or without the limits of a state, and (c) all Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the same (18 U.S.C. § 1151) (Child Welfare Information Gateway, 2012b).
 For more information on reporting in tribal communities, see Working with Children in Indian Country: Mandatory Reporting Obligations and Victims’ Rights in Federal Court (Hagen, 2013) at www.nationaldec.org/goopages/pages_downloadgallery/downloadget.php?filename=27649.pdf&orig_name=children_indian_country_-lh_12182013.pdf and Child Protection in Indian Country: A Handbook for Indian Health Service and Bureau of Indian Affairs (Center on Child Abuse and Neglect, n.d.) at www.icctc.org/IHS-BIA%20CPT%20Handbook/CPT.htm. The Tribal Law and Policy Institute at www.tribal-institute.org/lists/child.htm also offers related resources.
 Military OneSource at www.militaryonesource.mil/health-and-wellness/family-violence?content_id=282305 offers reporting instructions and a link to installation-specific contact information for family advocacy programs.
 For example, PREA requires juvenile detention centers to have reporting systems for sexual abuse. Typically, facilities are mandated to report suspicions of sexual abuse, and work in conjunction with child protection services, law enforcement agencies, and other reporting authorities so that reports are directed to appropriate responders in the facility and the community.
 Child Welfare Information Gateway (2014c) details specific penalties in different states and territories. See www.childwelfare.gov/pubPDFs/report.pdf. See Hagen (2013) for related information for Indian Country.
 Child Welfare Information Gateway (2012a) details laws related to immunity in different states and territories. See www.childwelfare.gov/pubPDFs/immunity.pdf. See Hagen (2013) for related information for Indian Country.
 Although some jurisdictions permit anonymous reporting, it is helpful if the agency receiving the report has reporter contact data in case additional information is needed. Child Welfare Information Gateway (2014b) details policies on inclusion of reporters’ identity in different states and territories. See www.childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/.
 Child Welfare Information Gateway (2013b) details information sharing policies in different states and territories. See www.childwelfare.gov/topics/systemwide/laws-policies/statutes/confide/.
 In some jurisdiction, the duty to report is triggered no matter how long ago the abuse occurred. In other states, time limitations are placed on the reporting obligation. Sometimes, but not always, statutes make time limitations explicit. If a jurisdiction does not have clear language regarding such time limitations in its statutes, it can be useful to seek legal guidance to answer this question. (Gudeman and Monasterio (2014).)
 Note that medical forensic examinations are generally not considered victim services.
 VAWA grantees who are not mandatory reporters who have questions about actions they can take in response to child sexual abuse disclosures are encouraged to seek appropriate legal counsel, as well as related training. For example, the Oregon Law Center offers a slide presentation at www.doj.state.or.us/wp-content/uploads/2017/03/confidentiality.ppt on survivor confidentiality for non-profit service providers, which addresses this scenario, among other issues (Dority & Selig, 2013).
 Gudeman and Monasterio (2014) offer considerations for involving youth when abuse reporting is triggered. Although their work speaks to older children, some of the tips are applicable.
 Child protective services or social services agencies typically maintain records of child abuse and neglect reports to aid in the investigation, treatment, and prevention of child abuse and neglect. In many jurisdictions, these records and investigative results are maintained in databases referred to as central registries. The type of information contained in these registries and agency records varies, as does accessibility to the information. (See Child Welfare Information Gateway (2013b).)
 See Child Welfare Information Gateway (2013b) at www.childwelfare.gov/topics/systemwide/laws-policies/statutes/confide/ for details about jurisdictional statutes. Persons entitled to access records typically include involved medical providers, medical examiners, child protective services, law enforcement personnel, attorneys involved in the case, and judges and other court personnel. Some jurisdictional statutes and policies allow access to some investigative records to the person who is the subject of a report, the victim, and the child’s caregiver, sometimes only at the conclusion of an investigation. Additionally, some information may be disclosed to insurance companies and/or in court, should legal proceedings occur. Some information may be used for research purposes.
 Note that all states and the District of Columbia allow minors who are age 12 years and above to consent to certain health care services. Some may also allow minors to seek or receive those services without their notifying parents/guardians. For examples, see Guttmacher Institute (2015). However, in most jurisdictions, prepubescent children do not have these rights. Health care providers should become familiar with the applicable laws of their jurisdiction.
 ) The identity of the reporter is specifically protected from disclosure to the alleged perpetrator in the majority of jurisdictions in the U.S. Release of the reporter’s identity is allowed in some jurisdictions under specific circumstances or to specific departments or officials (e.g., when information is needed for conducting an investigation). In some jurisdictions, reporters can waive confidentiality (Child Welfare Information Gateway, 2014b).
 This log is a facility risk management tool as investigative agencies are not bound by HIPAA. It is helpful to have a log if confronted about a protected report surfacing in public forums (e.g., the press), to show that the disclosure was legitimate when it left the facility. Confidentiality agreements among multidisciplinary team members can help avoid this problem.
 Bullet drawn in part from New Hampshire Attorney General’s Task Force on Child Abuse and Neglect (2008). See the AAP Committee on Child Abuse and Neglect (2010) for further information on HIPAA’s impact on clinical practice if child abuse or neglect is suspected.
 See Gudeman and Monasterio (2014).
 It may be useful for examiners to help children determine how to tell their caregivers about information that will be in the medical record (e.g., activities that the children think may get them in trouble or that will cause them embarrassment), as the caregivers likely will learn this information eventually via access to the investigative report.
 For information on the ability of a health care provider to communicate with persons identified by an individual involved in another individual’s care, see www.hhs.gov/hipaa/for-professionals/covered-entities/index.html (U.S. Department of Health and Human Services, n.d.). For general information about the HIPAA privacy rule, see www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html (U.S. Department of Health and Human Services, 2003). While advocates are usually on-call and must travel to the facility, it is common practice in many jurisdictions to inform victims and their families that a victim advocate is available at the facility to offer services, rather than asking if they would like an advocate to be called in. Victims and family members may feel they are inconveniencing advocates who must come to the facility just for them. Note, however, that some advocacy programs may choose not to operate in this manner for a variety of reasons (e.g., due to limited staffing capacity or significant advocate travel time to an exam facility).
 Contact the state, territorial, and/or tribal sexual assault coalition with questions about jurisdictional requirements. Coalitions and local community-based sexual assault programs are encouraged to provide clear guidance for advocates on reporting requirements and confidentiality policies in cases of child sexual abuse (e.g., see WSCAP, 2015b).
 Other forms may be used by the jurisdiction or the exam facility (e.g., additional consent and discharge forms).
 Some samples that historically have been collected are no longer recommended in many jurisdictions, unless the forensic history and physical exam indicate otherwise (e.g., collection of a saliva sample for “secretor status”).
 Material may be present on additional body surfaces from contact with blood or body fluids. Swabs available as a standard in each kit vary by jurisdiction.
 First responders such as law enforcement officers, child protective service workers, and emergency medical service providers also need materials, instructions, and forms, as well as training, to collect urine from children in a suspected alcohol- or drug-facilitated case, if a child cannot wait until arrival at the health care facility to provide a sample.
 For example, Tanner stage documentation, physical exam drawings consistent with prepubescent children, anogenital exam and knee-chest position drawings specific to prepubescent children, and forms and crime lab information specific to/for prepubescent patients.
 It is important to consider costs to the state, territory, tribe, federal agencies, and local community, and the ability of the community to cover costs. In some states, one state agency (e.g., the crime lab) assumes the costs. In others, the costs are passed on to local criminal justice agencies.
 Adams et al. (2015) recommended forensic sample collection for sexual contact that may have resulted in the exchange of biologic material within 24 hours in prepubescent children (Christian, 2011). However, some children may benefit from forensic evidence collection beyond 24 hours (Christian, 2011), especially in jurisdictions where DNA amplification is performed as part of crime lab analysis (Girardet et al., 2011). Because of this potential widened window of availability of forensic samples, many jurisdictions and clinical guidelines extend the time to 72 hours post abuse for prepubescent child acute examination.
 See the Technical Working Group on Biological Evidence Preservation (2013) at www.nist.gov/forensics/upload/NIST-IR-7928.pdf for a resource on biological evidence storage, tracking, preservation, and disposition, including recommendations and a glossary of related terms. See the National Institute of Standards and Technology at www.nist.gov/topics/forensic-science for additional resources.
 The Technical Working Group on Biological Evidence Preservation (2013) indicated that refrigeration of dried biological samples is generally unnecessary. See page 18 for a short-term storage conditions matrix.
 Note that some jurisdictions mandate a time frame for law enforcement to pick up forensic evidence.
 Some examples of challenges: a jurisdiction where the law enforcement agency is responsible for reimbursement, may choose not to authorize an examination due to lack of understanding of its value outside the possibility of forensic sample collection, especially in nonacute cases, lack of understanding of the need for an exam, or budgetary constraints.
 For example, the code for the presenting issue is sexual abuse, not a medical or mental health disorder of the child.
 See www.ovc.gov/publications/factshts/compandassist/welcome.html for information on state crime victims compensation programs (OVC, 2004).