| Typeotme: Sexual Assault ting Agency: _M\ SP Report to (Name): Tee Masel Ti ALES) 2, Email: M Yew gh SHU Tach VieinOther's Name(s) on_| sex Suspect’ Names) ace ,slnowlede recip ofthe tens) above om TPR, 1M ‘ri or ed mel ave ep:1S PATIENT UNDER AGE 18? tyes, age: DATE OF ASSAULT: SEXUAL ASSAULT EVIDENCE COLLECTION KIT INCIDENT REPORTED TO POLICE? NO: DO NOT RECORD VICTIN'S NAME ON KIT YES: IF YES, RECORD VICTIM'S NAME HERE: ‘CITY/TOWN IN WHICH INCIDENT OCCURRED: (OTHER EVIDENCE (eg. clothing) SUBMITTED INTRANSPORT BAG?) YES CONTAINS ITEMS THAT REQUIRE DRYING ‘SEPARATE COMPREHENSIVE TOXICOLOGY KIT USED? YES (tyes, Consnt or Comprehensive Toxicology Tesing MUST be completed and placed in toxcslogy kt) NO For HosPrTaL PERSONNEL voseraucune: S&. Litkes Aosocal = move nnmensyr, OR OFS A3IO— CUNICIANS) HA BIGHAZARD | KIT SEALED BY: Klegusia Chen T ACE KIT IN SECURED AREA, PLACED By: hen __ 7 oate: 5 we: "ZE0O LW. — GB. FOR POLICE PERSONNEL ‘CHAIN OF POSSESSION weoica. racury. SLf} ome S| 22 1/6 me OFA — = receweo rom: Kl POLICE IDENTIFICATION No! RECEIVED BY: AGENCY: oar Tae an RECEIVED FROM: MEDICAL FACILITY: al POLICE IDENTIFICATION NO: are: Me: ea RECEIVED BY: AGENCY: ATE: Te «= PROUPTLY HAND CARRY ALL EVIDENCE (FOR REPORTED OR NON-REPORTED INCIDENTS) TO THE CRINE LABORATORY, BIODEGRADABLE EVIDENCE- KEEP REFRIGERATED WHEN POSSIBLE PROVIDED FREE OF CHARGE BY The Commentecalth of Measachascls A Ceculive Ofte of Pablo Shyety "i INFORMATION PERTAINING TO ASSAULT & KIT TRACKING FORM ORM 2A PROVIDER SEXUAL CRIME REPORT k Dato of Areal ChyfTown of Asset ‘pect sounding at Une of Aastl: foe Fy (Check Oe) ott ep amo. oft Sa ethane au Cea Sanooepinede KIT NUMBER ‘sam complatad by 22 Tan eater & pean tate en gent txenge Stake SO aX tls report ‘Maseachusts Executive Office o Pub ally Reterch and Poly alas Ua = PAC 7264260 AND: Local poole sey mao igi RL ss