SART Nurse Survey  
Nurse’s Name __________________________ 
 
Questions related to the current exam  
Did you have everything that you needed to perform the exam (cart stocked, supplies available)? ___Yes ___ No  
 
I am going to state various services that are often offered to victims. Please tell me if you provided them, did not provide them or they were not applicable. Also note if the service was provided by someone else (i.e. ER doctor)  
 
Information about genital injury care      Y N  NA 
Information on sexually transmitted infections (STIs)    Y  N  NA 
Information on HIV/AIDS       Y N NA 
Prophylaxis for STIs         Y  N  NA 
Prophylaxis for HIV/AIDS        Y  N  NA 
Discuss risk of pregnancy        Y  N  NA 
Conducted a pregnancy test        Y N  NA Prophylaxis for pregnancy (Emergency Contraception)    Y  N  NA 
Post exam instructions; including injury care, medications and care  Y  N  NA 
Explain information concerning Victims Compensation Assistance   Y N  NA 
Comments:  
 
Did the officer or investigator who responded to the call:  
 
Display respect for the victim       Y  N  NA 
Communicate clearly with the victim      Y  N  NA 
Display an understanding of the victim’s experience    Y  N  NA 
Provide information on the investigative process/ next steps   Y  N  NA 
Explain information concerning Victims Compensation Assistance  Y  N  NA 
Comments:  
 
Did the advocate who responded to the call:  
 
Display respect for the victim       Y  N  NA 
Communicate clearly with the victim      Y  N  NA 
Display compassion for the victim       Y  N  NA 
Display an understanding of the victim’s story     Y  N  NA 
Provide information to the victim on next steps/services available   Y  N  NA 
Explain information concerning Victims Compensation Assistance  Y  N  NA 
Comments:  
 
What problems (if any) presented during this exam (process)  
With victim  
 
With Law Enforcement  
 
With Advocates 
 With ER staff 
 Family member/friends  
 
Other  
 
Did you provide referrals to the patient/victim? If yes, to what services?  
 
 
Questions related to your experience as a sexual assault forensic examiner (SAFE)  
1. How long have you been a SAFE?  


 
2. Where were you trained?  


When?  
 
3. How many exams do you estimate you have completed as a SAFE?  


 
4. Rate your experience/comfort with the exam process from 1-3 (scale)  


1    2   3  
Somewhat Experienced  Experienced   Very Experienced  
 
5. Rate your level of comfort with the contents of the forensic exam kit. 1-3 (scale)  


1    2   3  
Somewhat Comfortable  Comfortable   Very Comfortable  
 
6. Rate your comfort level with using the Med scope 1-3, (scale)  


1     2    3   DO NOT 
Somewhat Comfortable  Comfortable  Very Comfortable      USE 
 
7. Rate your comfort level with using the digital camera 1-3, (scale)   


1     2    3   DO NOT 
Somewhat Comfortable   Comfortable Very Comfortable     USE 
 
Questions related to your role on the SART team 
1. What is your greatest challenge as a SART nurse?  


 
 
2. What is your greatest need as a SART member?  


 
 
3. What changes would you suggest to the program?  


 
 
Is there anything else you would like to share about this exam/experience?  
 
 
Initials of interviewer ___________  
 
Tools for Evaluating & Assessing Your SART/SANE Program (p. 13) by Pennsylvania Coalition Against Rape, n.d. Retrieved from http://www.pcar.org/sites/default/files/resource-pdfs/tools_for_evaluating_assessing_your_sart-sane_program.pdf Reprinted with permission.