law enforcement request for sexual assault exam · ☐the lea could not obtain consent of the...

Rev 09/19 Law Enforcement Request for Sexual Assault Exam General Information For all reported cases of sexual assault under Texas Code of Criminal Procedure Article 56.06, a law enforcement agency (LEA) must: • Use this form to document the decision whether to request a sexual assault exam • Provide a copy of this completed form to: o both the health care facility and the sexual assault examiner or sexual assault nurse examiner who provides services to the victim that are related to the sexual assault; and o the victim or the person who consented to the sexual assault exam on behalf of the victim • Maintain the completed form in accordance with the LEA’s record retention policies The Office of the Attorney General will not process an application for reimbursement of the forensic costs of the sexual assault exam under Article 56.06 without a copy of this completed form. Sexual Assault Exam Information Victim Name (Last, First, Middle): Victim DOB: Male Female ☐ ☐ Date of Sexual Assault: Date Sexual Assault Was Reported to LEA: County Where Sexual Assault Occurred: LEA Name: LEA Case Number: LEA Point of Contact: LEA Phone Number: LEA Email Address: Hospital/Medical Facility Name: Hospital/Medical Facility Physical Address: Sexual Assault Exam Request Decision (LEA must certify, using the check boxes, whether a sexual assault exam was requested or declined.) Request ☐ I certify that the listed LEA requested a sexual assault exam for an assault reported within 120 hours of the assault under Article 56.06 (a-1) or outside of 120 hours of the assault and the LEA considered the exam appropriate under Article 56.06 (b). Decline to Request I certify that the listed LEA declined to request a sexual assault exam because: ☐ The LEA could not obtain consent of the victim, a person authorized to act on behalf of a victim, or an employee of the Department of Family and Protective Services [Article 56.06 (a-1)] ☐ The person reporting the sexual assault has made one or more false reports of sexual assault to the LEA and there is no other evidence to corroborate the current allegations of sexual assault [Article 56.06 (a-1)] ☐ The sexual assault was not reported within 120 hours of the assault and an exam was not considered appropriate by the LEA [Article 56.06 (b-1)] Authorized LEA Signature Date Printed Name Title

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Rev 09/19

Law Enforcement Request for Sexual Assault Exam

General Information

For all reported cases of sexual assault under Texas Code of Criminal Procedure Article 56.06, a law enforcement agency (LEA) must:

• Use this form to document the decision whether to request a sexual assault exam• Provide a copy of this completed form to:

o both the health care facility and the sexual assault examiner or sexual assault nurse examiner whoprovides services to the victim that are related to the sexual assault; and

o the victim or the person who consented to the sexual assault exam on behalf of the victim• Maintain the completed form in accordance with the LEA’s record retention policies

The Office of the Attorney General will not process an application for reimbursement of the forensic costs of the sexual assault exam under Article 56.06 without a copy of this completed form.

Sexual Assault Exam Information Victim Name (Last, First, Middle): Victim DOB: Male Female

☐ ☐

Date of Sexual Assault: Date Sexual Assault Was Reported to LEA: County Where Sexual Assault Occurred:

LEA Name: LEA Case Number:

LEA Point of Contact: LEA Phone Number:

LEA Email Address: Hospital/Medical Facility Name:

Hospital/Medical Facility Physical Address:

Sexual Assault Exam Request Decision (LEA must certify, using the check boxes, whether a sexual

assault exam was requested or declined.)

Request

☐ I certify that the listed LEA requested a sexual assault exam for an assault reported within 120 hours of the assault under Article 56.06 (a-1) or outside of 120 hours of the assault and the LEA considered the exam appropriate under Article 56.06 (b). Decline to Request I certify that the listed LEA declined to request a sexual assault exam because:

☐ The LEA could not obtain consent of the victim, a person authorized to act on behalf of a victim, or an

employee of the Department of Family and Protective Services [Article 56.06 (a-1)]

☐ The person reporting the sexual assault has made one or more false reports of sexual assault to the LEA andthere is no other evidence to corroborate the current allegations of sexual assault [Article 56.06 (a-1)]

☐ The sexual assault was not reported within 120 hours of the assault and an exam was not consideredappropriate by the LEA [Article 56.06 (b-1)]

Authorized LEA Signature Date

Printed Name Title

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