32 CFR § 105.11 - Healthcare provider procedures.

§ 105.11 Healthcare provider procedures.

This section provides guidance on medical management of victims of sexual assault to ensure standardized, timely, accessible, and comprehensive healthcare for victims of sexual assault, to include the ability to elect a SAFE Kit. This policy is applicable to all MHS personnel who provide or coordinate medical care for victims of sexual assault covered by this part.

(a) Standardized medical care. To ensure standardized healthcare, the Surgeons General of the Military Departments shall:

(1) Require the recommendations for conducting forensic exams of adult sexual assault victims in the U.S. Department of Justice Protocol be used to establish minimum standards for healthcare intervention for victims of sexual assault. Training for military sexual assault medical examiners and healthcare providers shall be provided to maintain optimal readiness in accordance with § 105.14 and section 539 of Public Law 113-291.

(2) Require that a SARC is immediately notified when a victim discloses a sexual assault so that the SARC can inform the victim of both reporting options (Restricted and Unrestricted) and all available services (e.g., SVC/VLC, Expedited Transfers, Military Protective Orders, document retention mandates). The victim can then make an informed decision as to which reporting option to elect and which services to request (or none at all). The victim is able to decline services in whole or in part at any time.

(3) Require the assignment of at least one full-time sexual assault medical forensic examiner to each MTF that has an emergency department that operates 24 hours per day. Additional sexual assault medical forensic examiners may be assigned based on the demographics of the patients who utilize the MTF.

(4) In cases of MTFs that do not have an emergency department that operates 24 hours per day, require that a sexual assault forensic medical examiner be made available to a patient of the facility consistent with the U.S. Department of Justice, Office on Violence Against Women, National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents (U.S. Department of Justice SAFE Protocol), through an MOU or MOA with local private or public sector entities and consistent with U.S. Department of Justice SAFENational Protocol for Sexual Assault Medical Forensic Examinations, Adult/Adolescent, when a determination is made regarding the patient's need for the services of a sexual assault medical forensic examiner.

(i) The MOU or MOA will require that a SARC be notified and that SAFE Kits be collected in accordance with § 105.12.

(ii) When the forensic examination is conducted at a civilian facility through an MOU or an MOA with the DoD, the requirements for the handling of the forensic kit will be explicitly addressed in the MOU or MOA. The MOU or MOA with the civilian facility will address the processes for contacting the SARC and for contacting the appropriate DoD agency responsible for accepting custody of the forensic kit.

(5) Require that MTFs that provide SAFEs for Service members or TRICARE eligible beneficiaries through an MOU or MOA with private or public sector entities verify initially and periodically that those entities meet or exceed standards of the recommendations for conducting forensic exams of adult sexual victims in the U.S. Department of Justice Protocol. In addition, verify that as part of the MOU or MOA, a SARC or SAPR VA is notified, and responds and meets with the victim in a timely manner.

(6) Require that medical providers providing healthcare to victims of sexual assault in remote areas or while deployed have access to the current version of the U.S. Department of Justice Protocol for conducting forensic exams.

(7) Implement procedures to provide the victim information regarding the availability of a SAFE Kit, which the victim has the option of refusing. If performed in the MTF, the healthcare provider shall use a SAFE Kit and the most current edition of the DD Form 2911.

(8) Require that the SARC be notified of all incidents of sexual assault in accordance with sexual assault reporting procedures in § 105.8.

(9) Require processes be established to support coordination between healthcare personnel and the SARC and SAPR VA. If a victim initially seeks assistance at a medical facility, SARC notification must not delay emergency care treatment of a victim.

(10) Require that care provided to sexual assault victims shall be gender-responsive, culturally competent, and recovery-oriented. Healthcare providers giving medical care to sexual assault victims shall recognize the high prevalence of pre-existing trauma (prior to present sexual assault incident) and the concept of trauma-informed care.

(11) If the healthcare provider is not appropriately trained to conduct a SAFE, require that he or she arrange for a properly trained DoD healthcare provider to do so, if available.

(i) In the absence of a properly trained DoD healthcare provider, the victim shall be offered the option to be transported to a non-DoD healthcare provider for the SAFE Kit, if the victim wants a forensic exam. Victims who are not beneficiaries of the MHS shall be advised that they can obtain a SAFE Kit through a local civilian healthcare provider at no cost to them in accordance with Violence Against Women Act as explained in with U.S. Department of Justice, Office on Violence Against Women, National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents.

(ii) When a SAFE is performed at local civilian medical facilities, those facilities are bound by State and local laws, which may require reporting the sexual assault to civilian law enforcement.

(iii) If the victim requests to file a report of sexual assault, the healthcare personnel, to include psychotherapists and other personnel listed in MRE 513 (Executive Order 13593), shall immediately call a SARC or SAPR VA, to assure that a victim is offered SAPR services and so that a DD Form 2910 can be completed.

(12) Require that SAFE evidence collection procedures are the same for a Restricted and an Unrestricted Report of sexual assault with the exception of the special requirements to safeguard PII in Restricted SAFE Kits in § 105.12.

(i) Upon completion of the SAFE and securing of the evidence, the healthcare provider will turn over the material to the appropriate Military Service-designated law enforcement agency or MCIO as determined by the selected reporting option.

(ii) Upon completion of the SAFE, the sexual assault victim shall be provided with a hard copy of the completed DD Form 2911. Advise the victim to keep the copy of the DD Form 2911 in his or her personal permanent records as this form may be used by the victim in other matters before other agencies (e.g., Department of Veterans Affairs) or for any other lawful purpose.

(13) Publicize availability of healthcare (to include mental health), and referral services for alleged offenders who are also active duty Service members. Such care will be administered in a way to respect and preserve the rights of the victim and the accused, and the physical safety of both.

(14) Require the healthcare provider in the course of, preparing a SAFE Kit for Restricted Reports of sexual assault:

(i) Contact the designated installation official, usually the SARC, who shall generate an alpha-numeric RRCN, unique to each incident. The RRCN shall be used in lieu of PII to label and identify evidence collected from a SAFE Kit (e.g., accompanying documentation, personal effects, and clothing). The SARC shall provide (or the SARC will designate the SAPR VA to provide) the healthcare provider with the RRCN to use in place of PII.

(ii) Upon completion of the SAFE, package, seal, and completely label of the evidence container(s) with the RRCN and notify the Military Service designated law enforcement agency or MCIO.

(15) Require that healthcare personnel must maintain the confidentiality of a Restricted Report to include communications with the victim, the SAFE, and the contents of the SAFE Kit, unless an exception to Restricted Reporting applies, in accordance with § 105.8. Healthcare personnel who make an unauthorized disclosure of a confidential communication are subject to disciplinary action and that unauthorized disclosure has no impact on the status of the Restricted Report; all Restricted Reporting information remains confidential and protected. Improper disclosure of confidential communications under Restricted Reporting, improper release of medical information, and other violations of this guidance are prohibited and may result in discipline pursuant to the UCMJ or State statute, loss of privileges, or other adverse personnel or administrative actions.

(16) Require that psychotherapy and counseling records and clinical notes pertaining to sexual assault victims contain only information that is required for diagnosis and treatment. Any record of an account of a sexual assault incident created as part of a psychotherapy exercise will remain the property of the patient making the disclosure and should not be retained within the psychotherapist's record.

(b) Selection, training, and certification. For the selection, training, and certification of healthcare providers performing SAFEs in MTFs, refer to standards in § 105.14.

(c) Timely medical care. To comply with the requirement to provide timely medical care, the Surgeons General of the Military Departments shall:

(1) Implement processes or procedures giving victims of sexual assault priority as emergency cases.

(2) Provide sexual assault victims with priority treatment as emergency cases, regardless of evidence of physical injury, recognizing that every minute a patient spends waiting to be examined may cause loss of evidence and undue trauma. Priority treatment as emergency cases includes activities relating to access to healthcare, coding, and medical transfer or evacuation, and complete physical assessment, examination, and treatment of injuries, including immediate emergency interventions.

(d) Comprehensive medical care. To comply with the requirement to provide comprehensive medical care, the Surgeons General of the Military Departments shall:

(1) Establish processes and procedures to coordinate timely access to emergency, follow-up, and specialty care that may be provided in the direct or civilian purchased care sectors for eligible beneficiaries of the Military Health System.

(2) Evaluate and implement, to the extent feasible, processes linking the medical management of the sexually assaulted patient to the primary care manager. To locate his or her primary care manager, a beneficiary may go to beneficiary web enrollment at https://www.hnfs.com/content/hnfs/home/tn/bene/res/faqs/beneficiary/enrollment_eligibility/who_pcm.html.

(e) Clinically stable. Require the healthcare provider to consult with the victim, once clinically stable, regarding further healthcare options to the extent eligible, which shall include, but are not limited to:

(1) Testing, prophylactic treatment options, and follow-up care for possible exposure to human immunodeficiency virus (HIV) and other sexually transmitted diseases or infections (STD/I).

(2) Assessment of the risk of pregnancy, options for emergency contraception, and any follow-up care and referral services to the extent authorized by law.

(3) Assessment of the need for behavioral health services and provisions for a referral, if necessary or requested by the victim.

(f) Other responsibilities.

(1) The Surgeons General of the Military Departments shall:

(i) Identify a primary office to represent their Department in Military Service coordination of issues pertaining to medical management of victims of sexual assault.

(ii) Assign a healthcare provider at each MTF as the primary point of contact concerning DoD and Military Service SAPR policy and for updates in sexual assault care.

(2) The Combatant Commanders shall:

(i) Require that victims of sexual assault are given priority treatment as emergency cases in deployed locations within their area of responsibility and are transported to an appropriate evaluation site, evaluated, treated for injuries (if any), and offered SAPR VA assistance and a SAFE as quickly as possible.

(ii) Require that U.S. theater hospital facilities (Level #, NATO role #) (See § 105.3) have appropriate capability to provide experienced and trained SARC and SAPR VA services and SAFE providers, and that victims of sexual assault, regardless of reporting status, are medically evacuated to such facilities as soon as possible (within operational needs) of making a report, consistent with operational needs.

(3) In accordance with DoDD 5136.13, the Director, Defense Health Agency (DHA), will:

(i) Ensure that this policy is implemented in the National Capital Region.

(ii) Identify a primary office to represent the National Capital Region in Military Service coordination of issues pertaining to medical management of victims of sexual assault.

(iii) Assign a healthcare provider at each MTF in the National Capital Region as the primary point of contact concerning DoD and Military Service SAPR policy and for updates in sexual assault care.

[78 FR 21718, Apr. 11, 2013, as amended at 81 FR 66448, Sept. 27, 2016]