National Guidelines on Management of Sexual Violence in Kenya

Annex 2: Post Rape Care Form (PRC)
Annex 2
PRC Form
Post Rape Care Form (PRC)
Day Month Year Province
Code
District Code
OP / IP No.
Last Name First Name Date
of
birth
Date Month Year Male
Fema
le
Contacts (Physical Address and Phone number)
Date and time of Examination Date and Time of Assault No. of Assailants
Alleged Assailants (Indicate relation to victim) Unknown Known
Place Assault Occurred
Chief complaints / Presenting Symptoms
Circumstances surrounding the incident (survivor account) remember to record penetration (how, where, what was used?
Presence of struggle?)
Type pf Assault Use of condom? Incident already reported to police?
Oral Yes Yes (indicate which station and when)
Vaginal No No
Anal
Attended a health facility before this
Where you treated?
Were you given any
one?
notes?
Other sex No Yes Yes
Yes (indicate which one and when) No No
Comments
Significant medical and/or surgical history
OBS /GYN History
Pari
Contraception
LMP
Known
Date of last consensual sexual
ty
type
Pregnancy?
intercourse
Yes
N
o
General Condition BP Pulse Rate RR Temp Demeanor /Level of anxiety (calm or not)
43