National Guidelines on Management of Sexual Violence in Kenya

RAPE TRAUMA COUNSELING DATA FORM
Sex Has the client reported to the
0 No 1 Yes
1 Male 2 Female
Age (years)
Education
police?
0 No 1 Yes
If not, name reason(s)
a) Is the client willing to report
to the police?
If not, name reason(s)
2 nd Visit
a) Disclosure of SV
0 None 0 No 1 Yes 0 No 1 Yes
1 Primary If not, name reason(s) b) Disclosure HIV results
2 Secondary
Client referred from?
0 No 1 Yes
3 Post Secondary/Technical 1 VCT services 2 Police stations c) PEP adherence
Marital Status
3 Health Facilities 9 Other 0 No 1 Yes
0 Never 1 Married
Was the 1 st dose of PEP
administered?
If not, name reason(s)
2 widowed 3 Separated/Divorced 0 No 1 Yes d) Still taking PEP
Type of assault
If not, name reason(s) 0 No 1 Yes
1 Penile anal rape 2 Penile vaginal rape 1 Presented after
72 hours
2 Client declined
3 rd Visit
3 Use of objects in vagina 9 Other Is disclosure done so far ?
4 Use of objects in anus
Was EC administered?
0 No 1 Yes
9 Other 0 No 1 Yes 2 N/A Comments
Client seen
If not, name reason(s)
4 th Visit
1 Individual 2 With partner Comments
3 With guardian/parent 4 With friend/relative
Did client know HIV status
before the assault?
5 th Visit
9 Other 0 No 1 Yes HIV Test done
Services required by client
If Yes, 0 Negative 1 Positive
Was the PRC 1 form filled?
0 Negative 1 Positive Disclosure of SV
0 No 1 Yes
If not, name reason(s)
Who is the assailant?
1 st Visit
0 No 1 Yes
a) HIV test done Disclosure of HIV Results
0 No 1 Yes 2 Declined 0 No 1 Yes
If Yes, 0 Negative 1 Positive Pregnancy Test done
b)Pregnancy Test done
0 No 1 Yes 2 N/A
0 Known 1 Unknown Results 0 Negative 1 Positive
0 No 1 Yes 2 N/A
Results 0 Negative 1 Positive
Comments
If known, specify relationship
c) Disclosed SV
0 No 1 Yes
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