Victims of sexual assault may receive a sexual assault forensic examination by a medical provider who may or may not be a trained sexual assault forensic examiner. Medical providers assess victims’ clinical conditions; provide appropriate treatment and medical referrals; and, given consent by the victim, collect forensic evidence through a sexual assault forensic examination that may follow steps and use supplies from a sexual assault evidence collection kit. Under its protocol for sexual assault forensic examinations, DOJ recommends that medical providers collect a range of physical evidence, which can include, but is not limited to, clothing, foreign materials on the body, hair (including head and pubic hair samples and combings), body swabs, and a blood or saliva sample for DNA analysis and comparison. In addition, sexual assault forensic exams typically include documenting biological and physical findings such as cuts or bruises, either in writing or photographs, and a recording of a victim’s medical forensic history such as the time and nature of the assault. Once the exam is complete, medical providers preserve the collected evidence, which may include packaging, labeling, and sealing evidence collection kits and storing kits in a secure location. Medical providers typically perform such exams only for acute cases of sexual assault, such as in cases where the assault occurred within the previous 72 to 96 hours, when the physical and biological evidence on a person’s body or clothes is considered most viable. DOJ, IAFN, and the American College of Emergency Physicians (ACEP) recommend that sexual assault forensic exams be performed by specially trained medical providers—or sexual assault forensic examiners (examiners). These examiners include physicians, physician assistants, nurse practitioners, and other registered nurses who have been specially educated and completed clinical requirements to perform sexual assault forensic exams. Sexual assault nurse examiners (SANE) —a particular type of sexual assault forensic examiners—are registered nurses, including nurse midwives and other advanced practice nurses, who have received specialized education and have fulfilled clinical requirements to perform sexual assault forensic exams. Examiner programs have been created in hospital or non-hospital settings whereby specially trained examiners are available to provide first-response care and exams to sexual assault victims. Additionally, for pediatric victims, specially trained examiners may perform medical forensic exams in a child-specific facility, such as a child advocacy center. DOJ, IAFN, and some states have issued guidelines pertaining to the minimum level of training examiners should receive in order to properly collect and preserve evidence, identify victims’ medical and emotional health care needs, and provide counseling and referrals for victims. These guidelines include recommendations of objectives and topics that training programs should cover. For example, in their guidelines, DOJ and IAFN recommend that examiners receive comprehensive training that covers such topics as how to identify and deliver proper elements of a victim-centered sexual assault forensic examination where victims are fully informed of their options during and after the exam; how to assess patients and provide culturally competent medical care, including testing and delivery of prophylaxis for sexual transmitted infections and pregnancy; how to collect and document evidence in a way that protects the evidence’s integrity; how to testify about findings in court; and how to protect the chain of custody of evidence and coordinate care across a multidisciplinary team. The goal of training, as outlined in the DOJ and IAFN guidelines, is for examiners to be able to effectively evaluate and address victims’ health concerns, minimize their trauma and promote their healing during and after the exam, and to detect, collect, preserve, and document physical evidence related to the assault for potential use by the legal system. In addition, registered nurses can become certified SANEs through IAFN to perform exams, though no such national certification exists for examiners who are not registered nurses. Depending on the state, examiners may also become certified through a state certifying body, such as a state board of nursing. There are no federal requirements concerning the training or availability of examiners in health care facilities outside of military, correctional, and Indian Health Service facilities. While a Joint Commission accreditation standard requires hospitals to establish policies for identifying and assessing possible victims of sexual assault and to train staff on those policies, each hospital is responsible for determining the level of specificity of such policies, including the minimum level of training required of its medical staff that perform exams. Some states may have established minimum training requirements of nurses that perform sexual assault forensic exams and require nurses to become certified either through the IAFN or the state. As authorized by VAWA, DOJ administers several grant programs that aim to, among other things, improve response to and recovery from four broad categories of victimization—domestic violence, sexual assault, dating violence, and stalking. The grant programs aim to address these categories of victimization through a range of activities, including public education and prevention; improved collaboration among stakeholders; training of law enforcement, prosecutors, court personnel, and victim service providers; strengthening victim services; developing and implementing more effective police, court, and prosecution policies and services; and improving data collection and communication systems related to these crimes. According to DOJ officials, there are three key VAWA authorized grant programs administered by DOJ’s Office on Violence Against Women (OVW) that can be used by grant recipients to fund or train sexual assault forensic examiners. In March 2011, the Indian Health Service within the Department of Health and Human Services implemented a new policy, through its Indian Health Manual, that all Indian Health Service-operated facilities must provide patients age 18 and older who present themselves for sexual assault services with access to an exam on-site or by referral. Victims who are referred elsewhere must be transported within 2 hours of the victim’s presentation at the medical facility. All registered nurses, advanced practice nurses, physicians, and physician assistants new to caring for adult and adolescent sexual assault patients must complete 40 hours of examiner training as well as clinical practice experience under the guidance of a forensically experienced medical provider. All examiner training and clinical practice experience must conform to the SANE educational requirements of the IAFN and the DOJ National Sexual Assault Medical Examining Training Standards. Department of Health and Human Services, Indian Health Service, “Chap. 29—Sexual Assault.” Pt. 3 in Indian Health Manual (Rockville, Md.: May 16, 2014). Services-Training-Officers-Prosecutors Violence Against Women Formula Grant Program (STOP Grant Program): The purpose of the STOP grant program, the largest of the three key grant programs, is to help states, courts, and local governments develop and strengthen effective law enforcement and prosecution strategies to combat violent crimes against women and to develop and strengthen victim services in cases involving violent crimes against women. Under the STOP grant program, there are 20 statutorily defined purposes for which funds may be used, one of which pertains directly to training examiners in the collection and preservation of evidence, analysis, prevention, and providing expert testimony and treatment of trauma related to sexual assault. The STOP Grant Program is a formula grant program in which all states and territories are awarded a minimum amount of $600,000 plus an additional amount based on state population size. STOP Grant Program awards may support up to 75 percent of the costs of all projects, including the cost of administering those subgrants; the remaining 25 percent of costs must be covered by nonfederal match sources. The average STOP grant award to states in fiscal year 2015 was about $2.5 million and ranged from roughly $600,000 to $13.2 million. Once states receive funds, a designated state agency—referred to as the state STOP administrator—is responsible for distributing funds to subgrantees based on the state’s own subgrant award process. However, state STOP administrators must allocate funds according to a statutorily defined formula—that is, 25 percent of funds must be distributed for law enforcement, 25 percent for prosecutors, 30 percent for victim services, 5 percent to state and local courts, and 15 percent for discretionary distribution within the program purpose areas. We refer to STOP subgrantees as grantees throughout this report. Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program (Arrest Grant Program): The purpose of the Arrest Grant Program is to encourage state, local and tribal governments and courts to treat domestic violence, dating violence, sexual assault, and stalking as serious violations of criminal law requiring the coordinated involvement of the entire criminal justice system. Eligible applicants include states, territories, and units of local government; Indian tribal governments; state, local, tribal, and territorial courts; victim service providers; state or tribal sexual assault or domestic violence coalitions; and government rape crisis centers. For the Arrest Grant Program, at least 25 percent of appropriated funds must be allocated to activities that address sexual assault. Developing, implementing, or enhancing examiner programs, including the hiring and training of such examiners, is 1 of 22 purpose areas for which Arrest Program grant funding can be used. The average grant award in fiscal year 2015 was $601,361 and ranged from $224,668 to $900,000. Rural Sexual Assault Domestic Violence, Dating Violence, and Stalking Assistance Program (Rural Grant Program): The purpose of the Rural Grant Program is to enhance the safety of rural victims of sexual assault, domestic violence, dating violence and stalking, and support projects uniquely designed to address and prevent these crimes in rural areas. At least 75 percent of total Rural Grant Program funding must be allocated to eligible entities in “rural states,” as defined by VAWA 2013. Eligible entities include states, territories, Indian tribes, local governments, and nonprofit entities including tribal nonprofit organizations. In addition, at least 25 percent of funds appropriated for the Rural Grant Program must be allocated to activities that address sexual assault in rural areas. Regardless of whether a grantee is from a rural or nonrural state, funds must be used for services and activities in a rural area or rural community. Grantees are required to implement at least one of five statutorily defined strategies, one of which includes developing, enlarging, or strengthening programs addressing sexual assault, including examiner programs. The average grant award in fiscal year 2015 was $599,997 and ranged from $144,000 to $999,993. Across these three grant programs, a total of $186.7 million in funds was awarded to grantees in fiscal year 2015. (See table 1.) Organizations that receive DOJ grant awards (or subgrant awards) through the STOP, Arrest, and Rural Programs are required to submit annual or biannual reporting forms to the OVW that include information about how they used grant funding, including specific information about whether funding was used to provide training for or fund sexual assault forensic examiners. DOJ officials told us that funding from additional DOJ grant programs may be used to fund, train, or support the training of examiners, though officials stated that the use of such grant funding for these purposes is limited. Such programs include the Office for Victims of Crime’s Training and Technical Assistance Center and its National Sexual Assault TeleNursing Center demonstration project as well as the Bureau of Justice Assistance’s Byrne Justice Assistance Grant Program. In addition, OVW also administers the Technical Assistance Grant Program, which aims to provide direct technical assistance to existing and potential grantees to successfully implement projects supported by OVW grant funds. The Technical Assistance Program is aimed at providing in-person and online educational training opportunities, peer-to-peer consultations, site visits, and other types of tailored assistance to help grantees, including STOP, Arrest, and Rural Program grantees, implement grant- funded activities effectively. Although Technical Assistance Program providers could also use awarded funding to provide training that would help examiners to perform at a higher level of proficiency, DOJ officials noted that such providers do not provide comprehensive classroom or clinical training to medical providers aspiring to become an examiner. According to officials from HHS, as of September 2015, HHS did not administer any grant programs that are used to train or fund examiners nor has it issued guidance or requirements concerning the training of medical professionals on conducting exams or the availability of examiners. Although HHS was authorized through VAWA 2013 to administer the Consolidated Grants to Strengthen the Healthcare System’s Response to Domestic Violence, Dating Violence, Sexual Assault, and Stalking, funds were never appropriated to HHS for this program. In addition, officials from both agencies told us that, as of September 2015, DOJ and HHS had not collaborated on any activities concerning the training of medical providers on conducting sexual assault forensic exams or the availability of trained examiners. In 49 states, at least one STOP, Arrest, or Rural Program grantee— including STOP subgrantees—reported using federal grant funds to provide training for sexual assault forensic examiners in 2013, the most recent year for which complete data were available. Grantees used funds for a variety of examiner training activities. In addition to training examiners, grantees in 26 states funded examiner staff positions in 2013, although grantees in these states funded less than one full-time equivalent (FTE) examiner position, on average. In nearly all states in 2013, at least one STOP, Arrest, or Rural Program grantee reported using federal grant funds to provide training for sexual assault forensic examiners in 2013. Specifically, in 2013, approximately 227 grantees in 49 states reported using grant funds to provide training for over 6,000 examiners. Most examiners (4,936) received training from STOP grantees. (See table 2.) However, on the basis of available data, it is unclear how many examiners received comprehensive examiner training versus other training that could help enhance their ability to serve victims. Based on interviews with grantees in some of our six selected states and a review of grantee progress reports submitted to DOJ in 2013, the type of training that grantees provided for examiners ranged from comprehensive examiner training and certification to training on specific topics that enable examiners to improve their response to victims. Grantees reported using federal grant funds to provide examiners with the following types of training: Comprehensive Examiner Training or Certification: Grantees reported using funds to provide comprehensive examiner training that, for example, included 40 or more hours of classroom training as well as, in some cases, clinical practice training. For example, in 2014, a Wisconsin grantee used STOP grant and state budget funds to provide five 40-hour training courses and three clinical skills labs for examiners, training a total of 115 new examiners. Although the state neither offers nor requires examiner certification, those that participated in the training could become certified through IAFN. In addition, the statewide examiner training program in Colorado, which is partially supported using STOP grant funds, both trained and certified 74 new examiners in 2014. Examiner Recertification or Continuing Education Training: In addition to comprehensive examiner training or certification, some grantees used grant funds to offer periodic recertification or “refresher” training so that examiners can maintain competency. For example, a grantee in Kansas provided refresher training to examiners who were identified by forensic lab evaluation forms as having errors in evidence collected through sexual assault forensic exams. Topical Training: Some grantees reported providing training to examiners on specific topics, such as interviewing and photography techniques, court room testimony, or victim confidentiality protocols. For example, officials from the statewide examiner training program in Colorado told us that in the past they have used both STOP and Arrest Program funds to provide courtroom training for examiners. Other grantees reported providing training to examiners on working with certain types of victims, such as lesbian, gay, bisexual, transgender, disabled, or elderly victims. The extent of examiner training efforts supported with STOP, Arrest, and Rural Grant Program funds varied by state. In 2013, the total number of examiners who received training funded through these grant programs in each state ranged from 0 to 604. In half of the states (26), fewer than 100 examiners received training and in 12 of these states fewer than 25 examiners received training. (See figure 1.) Further, based on interviews with grantees in selected states, we found that while some grantees used funds to support statewide comprehensive examiner training programs, other grantees used funds to provide training in specific locations, such as a single county or hospital. For example, at least one grantee each in Colorado, Florida, Massachusetts, and Wisconsin used STOP or Arrest Program funds, in combination with other funding, to support statewide comprehensive examiner training programs. However, Jefferson County in Oregon used its Rural Program funds for one examiner’s recertification as well as other continuing education training for four examiners at a local hospital in 2014. Additionally, the Colorado Sexual Assault Response Project used Arrest Program funds to provide training for 44 examiners in rural areas to perform exams. The number of grantees in each state that used grant funds to provide training for examiners also varied. For example, in 2013, the number of grantees that reported providing training for examiners per state ranged from 0 to 19. While 12 grantees provided training for a total of 43 examiners in North Carolina, two grantees provided training for a total of 347 examiners in Illinois in 2013. (For more detailed information on the number of grantees that reported providing training for examiners and the number of examiners provided training in each state by grant program, see appendix I.) Some entities used funds from DOJ’s Technical Assistance Program to provide training for examiners on a national scale. DOJ officials told us that although OVW does not fund any Technical Assistance Program award recipients to provide classroom or clinical training for examiners, some may provide national training that assists examiners in developing knowledge, experience, or skills to perform at a higher level of proficiency. For example, in 2014 IAFN used Technical Assistance Program funds to provide online and in-person training for examiners on topics such as treating transgender victims of sexual assault and payment policies for forensic exams. In the reporting period January through June 2014, Technical Assistance Program award recipients provided training for 1,772 examiners. DOJ officials told us that the majority of these examiners (1,609) received training provided by five Technical Assistance Program award recipients. DOJ officials told us that the STOP, Arrest, and Rural grant programs are the key grant programs from which funds are available to train examiners, though grantees may use funds to address four broad categories of victimization—sexual assault, domestic violence, dating violence, and stalking. Further, within the category of sexual assault, there is an extensive range of issue areas that grantees can choose to address, including providing training for examiners. For example, grantees may choose to use funds to pay for victim services or to train other professionals, such as law enforcement officers, judges, and prosecutors, on issues related to sexual assault. Of all STOP, Arrest, and Rural Program grantees, 8.4 percent reported using grant funds specifically to provide training for examiners in 2013. According to DOJ and state officials, grantees might not use STOP, Arrest, or Rural Grant Program funds to provide training for examiners for a variety reasons, including competing demands for the use of funds and a lack of competitive grant applications from entities seeking funds for this purpose. For example, officials in Florida reported that STOP grant funds are not used to provide training for examiners but are instead targeted towards other areas, such as law enforcement, victim services, or developing and supporting sexual assault response teams. DOJ officials and state STOP administrators also told us that not all grant applications seeking funds to train examiners may be approved. For example, DOJ officials told us that grant applications may be denied if they do not meet the standardized criteria OVW uses in the review of applications for the Arrest and Rural programs or, despite meeting OVW’s criteria and scoring well, other applications score better. Additionally, officials told us that it is possible that few applicants seek funding to train examiners. For example, the Nebraska STOP Administrator told us that due to a lack of knowledge that grant funds can be used for this purpose, the state received only one application to train examiners, which was not approved due to competing demands for available funds. Some grantees in our six selected states that did not use STOP, Arrest, or Rural Grant Program funds to provide training for examiners used other funds, such as funds from state and hospital budgets or nonprofit organizations, to train examiners. In Nebraska, for example, examiner training is primarily funded by a hospital system that also employs over half of the examiners in the state (24 out of 43 examiners). Although Oregon did not use federal funds to provide training for examiners, officials told us that the Oregon Sexual Assault Task Force, a statewide nonprofit organization, uses grant funds from the state department of justice to offer 40-hour comprehensive examiner training courses two times per year. Finally, some grantees told us that they used federal grant funds to provide sexual assault exam overview training for health and other professionals. For example, one grantee in Massachusetts told us that they used grant funds to provide basic forensic evidence collection training to staff at hospitals that did not have trained examiners available. In half of the states, at least one STOP, Arrest, or Rural grantee funded examiner staff positions in 2013. Approximately 75 grantees in 26 states funded roughly 50 FTE examiner positions in 2013, most of which (46 FTE examiner positions) were funded by STOP grantees. (See table 3). In these 26 states, grantees funded, on average, less than one FTE examiner position each, ranging from 0.1 to 9.8 FTEs in 2013. Further, few STOP, Arrest, or Rural grantees used funds to pay for FTE examiner positions in 2013. In 2013, approximately 2.5 percent of STOP grantees, 5.2 percent of Arrest grantees, and 6.3 percent of Rural Program grantees reported using grant funds for FTE examiner positions. Information from interviews with officials in two of our six selected states suggests that grantees that fund examiner positions may fund an examiner to act as an examiner program coordinator. Program coordinator duties may include overseeing the operations of examiner programs, training examiners, providing technical assistance, and providing forensic exams. For example, officials in both Massachusetts and Wisconsin told us that STOP Grant Program funds were used to pay for a statewide coordinator in FY 2014. In addition, grantees also used grant funds to pay for examiners to be on-call. For example, a grantee in Hawaii reported that STOP grant funding allowed them to provide on-call pay to examiners in the state. According to our literature review and the experts we interviewed, only limited nationwide data exist on the availability of sexual assault forensic examiners—that is, both the number of practicing examiners and health care facilities that have examiner programs. While IAFN reported that, as of September 2015, there were 1,182 nurses with active IAFN SANE certification in the United States, such data do not represent all practicing examiners nationwide. For example, the data do not account for examiners who completed training through an IAFN or a state training program but never became certified or were certified through another entity, such as a state board of nursing. IAFN also collects data on examiner programs nationwide—that is, data on hospitals, clinics, and other sites where examiners practice. Such data provide an indication of the availability of examiners, but the data are also limited. While 703 examiner programs nationwide voluntarily reported to IAFN’s examiner program database, as of September 2015, IAFN officials noted that the database is often not up-to-date and some health care settings where sexual assault forensic exams are conducted, such as child advocacy centers, are not represented. In addition, data collected on staffing characteristics of examiner programs are often unavailable in the IAFN examiner program database. For example, only about one-third of the examiner programs reported on the number of examiners practicing in their program and about one-third reported on whether examiners were available on-site versus on-call. In three of six selected states, STOP administrators or officials from sexual assault coalitions were able to provide estimates of the number of practicing examiners and, in all six states, they were able to provide information on the estimated number of examiner program locations in their state. Of states that reported, the number of practicing examiners and examiner programs varied by state. (See table 4.) However, such data may also present an incomplete picture of the availability of examiners. For example, only one of the six selected states has a system in place to formally track the number and location of examiners. Instead, officials generally reported on the estimated number of examiners or examiner locations that were part of a statewide examiner program or were identified through an ad hoc data collection effort. Although data are limited, STOP administrators and sexual assault coalition officials in all six selected states nevertheless told us that the number of examiners available does not meet the need for exams within their states. For example, coalition officials in Wisconsin told us that nearly half of all counties in the state do not have any examiner programs available, and coalition officials in Nebraska told us that most counties in the state do not have examiner programs available. In addition, in four of six selected states—Colorado, Florida, Nebraska, and Wisconsin—state STOP administrators and coalition officials told us that few or some health care facilities in their state have examiners available. As a consequence, officials said victims may need to travel long distances to be examined by a trained examiner or be examined by a medical professional without specialized training. For example, the Colorado STOP administrator explained that although there is an examiner program available in all regions of the state, not all hospitals participate in Colorado’s statewide examiner program. As a result, in the rural Western region of Colorado, for example, victims may have to travel more than an hour to reach a facility with examiners available. While in the other two selected states—Massachusetts and Oregon—state STOP administrators and coalition officials stated that some or most facilities have examiners available, they noted that there is still a need for additional capacity to reduce the burden on those examiners who are available or to make examiners available in a number of areas where examiners are currently unavailable. For example, Massachusetts coalition officials told us that there is an ongoing need for examiners across the state. There were few or in some cases no examiners available in rural areas, according to state STOP administrators or coalition officials we interviewed in selected states. STOP administrators and coalition officials in Colorado, Florida, and Wisconsin told us that in rural areas there may be only one examiner or one examiner program available across multiple counties. For example, Colorado coalition officials told us that of the five rural counties in Central Colorado, only one county had an examiner available. Alternatively, according to the Nebraska STOP administrator, some victims might have to travel to a major metropolitan area to reach a facility with examiners available, which could take 2 or more hours. In general, state STOP administrators and coalition officials explained that it could take a victim 30 minutes or less in urban areas to up to 2 hours in rural areas to reach a facility that has an examiner available. STOP administrators and coalition officials we interviewed explained that the availability of examiners in rural areas is challenging for a number of reasons, including the limited availability of health care providers generally, weather-related travel restrictions that can affect the time and distance victims must travel to reach a facility with an examiner, difficulty recruiting qualified nurses to undergo training, and a lack of capacity in rural areas to provide examiner training opportunities. Even in some urban areas the availability of examiners may be limited, according to state STOP administrators or coalition officials we interviewed. For example, Wisconsin coalition officials explained that just one of the five major hospitals in Milwaukee has examiners available, and some victims may be unwilling to travel to that hospital to receive an exam from an examiner. In addition, Florida coalition officials told us that even in urban areas there are only a few specialized places where victims can receive an exam from a trained examiner. In health care facilities where examiners are available, they are typically available through hospitals on an on-call basis, according to literature we reviewed as well as all STOP administrators and coalition officials we interviewed. Results from a 2005 national survey of examiner programs showed that most programs (60 percent) were administered through hospitals and 71 percent of examiner programs used staffed examiners on a part-time, on-call basis. According to literature we reviewed as well as experts and Colorado, Florida, and Oregon coalition officials we interviewed, on-call examiners may serve “dual roles”—that is, they simultaneously work as emergency department nurses and cover their on-call examiner shift. Specifically, results from the 2005 survey showed that about one-quarter of all examiner programs used nurses who overlapped their emergency department shifts with their on-call examiner shifts. Alternatively, according to the STOP administrators in Colorado and Oregon, examiners in some facilities or rural areas may not work based on an official on-call schedule. Instead, an examiner program coordinator will call through a list of examiners practicing in a region of the state when a victim arrives to find an examiner available to conduct the exam. The Colorado STOP administrator noted, however, that it is often the case that no examiners are available and the coordinator, who is also a trained examiner, will ultimately come in to the hospital to perform the exam instead. In addition, among facilities that have examiners available, the number of examiners available varies and may not provide enough capacity for facilities to offer examiner coverage 24 hours, 7 days a week, according to state STOP administrators and coalition officials we interviewed. Nebraska coalition officials, for example, told us that while one hospital in Omaha has a team of 26 examiners available, other facilities in the state may have as few as three examiners available. Further, Florida coalition officials and the Colorado STOP administrator told us that there are few facilities in their states able to offer full coverage with examiners available 24 hours, 7 days a week. For example, Memorial Hospital in Colorado Springs is the only facility in Colorado that has enough examiners available to provide examiners on-staff 24 hours a day, 7 days a week, according to Colorado officials we interviewed. Staff from a rural hospital in Oregon explained that although it has two on-call examiners and one additional examiner available if needed, there are not enough examiners available to provide on-call coverage 24 hours, 7 days a week. According to state STOP administrators and coalition officials we interviewed in six selected states, health care facilities may have their own protocols in place concerning the expected response time of on-call examiners, transferring victims to facilities that have examiners available, and paging on-call examiners. Florida coalition officials as well as the Massachusetts and Oregon STOP administrators told us, for example, that facilities with examiners available may have an agreement in place that specifies the expected response time of examiners. State STOP administrators or coalition officials we interviewed in five of six selected states told us that, in general, examiners are expected to arrive at a facility within 30 minutes to 1 hour of being paged in urban areas, though it could take longer in rural areas. Some STOP administrators or coalition officials in selected states informed us that facilities that do not have examiners available may transfer or encourage victims to go to another facility with examiners available, or they may be treated by an untrained medical professional. One coalition official noted that victims who are referred elsewhere for exams often do not follow through and thus never receive an exam. This may be because, according to Florida coalition officials, victims may be responsible for transporting themselves or they may be transported on a case-by-case basis by law enforcement. Last, officials told us that the timing of when on-call examiners are paged varies. For example, Colorado and Florida officials told us that, if a victim is being transported to another hospital, the destination facility may not page the on-call examiner until the victim has arrived. However, officials from one hospital in rural Oregon and Wisconsin coalition officials explained that, in their states, local law enforcement will notify the destination hospital when a victim is being transported to their hospital so that an examiner can be paged in advance. According to state STOP administrators and state sexual assault coalition officials we interviewed in six selected states, maintaining a supply of trained examiners that meets communities’ needs for exams is challenging for multiple reasons, including the limited availability of training, a lack of technical assistance and other resources, weak stakeholder support for examiners, and low examiner retention. In order to address these challenges, state officials told us that they have employed a variety of strategies, such as offering web-based training courses or clinical guidance or support for examiners, clinical practice labs, mentorship programs, and developing multidisciplinary teams within communities that respond to cases of sexual assault. Limited availability of training. Officials in five of six selected states told us that the limited availability of classroom, clinical, or continuing education training is a barrier to maintaining a supply of trained examiners. Regarding classroom training, some officials told us that training may only be offered once per year in their states. Additionally, officials from both Florida and IAFN told us that there is a need for qualified instructors to run training sessions. Experts and officials from Colorado, Nebraska, and Oregon also told us that medical professionals in rural areas may have difficulty completing the clinical training necessary to become an examiner. Obtaining clinical experience, such as performing exams under the supervision of a trained examiner, is a particular challenge in rural areas where hospitals may treat only a few sexual assault cases per year. One official in Nebraska told us that trained examiners in rural areas might not feel competent to perform exams due to the low number of cases they treat. A lack of continuing education opportunities may also pose a challenge for examiners in maintaining the skills necessary to perform exams. For example, the National Sexual Violence Resource Center (NSVRC) reported that, based on common challenges identified through a survey of and group discussions among examiner program coordinators, maintaining competency may be difficult for nurses in rural areas due to a low volume of patients presenting in need of exams and limited access to ongoing and advanced training. Officials told us that they have been able to increase the availability of examiner training through alternative training methods such as web- based training courses and simulated clinical training. For example, officials in Colorado told us that their state’s web-based examiner training program has made training less expensive and has increased examiner recruitment. Officials in Wisconsin told us that they developed a clinical training lab that allows examiners to gain hands-on experience by performing elements of exams on models who are experienced teaching assistants and hired for the purpose of training new examiners. Further, in 2014, a DOJ-funded evaluation of examiner training programs found that a web-based training course may help increase the availability of trained examiners; the study also found that implementing web-based training had benefits such as decreasing the costs associated with attending in- person training, expanding training opportunities to remote areas, and allowing examiners to be trained by national experts. Lack of technical assistance and other supportive resources. Officials in four of six selected states told us that the limited availability of technical assistance and other supportive resources for examiners poses a challenge to maintaining a supply of trained examiners. For example, officials in Florida, Nebraska, Oregon, and Wisconsin explained that, in general, there is a lack of mentorship opportunities and leadership within the examiner community. Officials also noted that the sustainability of examiner programs may be threatened by a lack of internal capacity, such as not having a full-time, paid examiner program coordinator available. Further, in its survey of and group discussions with examiner program coordinators, NSVRC found that examiners and examiner programs needed technical assistance and support in the following areas: aspects of performing exams, training, leadership development and policy issues, and examiner program sustainability. Specifically, examiners needed technical assistance and support on topics such as testifying in court; professional development; performing certain types of procedures, such as a colposcopy or anogenital photography; and working with special populations. Officials we spoke to told us about strategies that can be used to increase support for examiners and examiner programs, such as offering web- based technical assistance. For example, officials in Massachusetts told us that through their National Sexual Assault TeleNursing Center, trained SANEs provide remote clinical guidance to two hospitals in the state that do not have trained examiners available. In addition, officials from Colorado told us that an examiner program coordinator in an urban hospital in the state provides volunteer on-call technical assistance and clinical guidance to examiners in rural parts of the state, where those resources are not otherwise available. Further, one study we reviewed found that several states were engaged in promising practices to increase support for examiners, such as implementing state-wide mentorship programs, developing regional examiner list-serves and online discussion boards, creating formal leadership positions with in the examiner community, and requiring examiner program evaluations. Weak stakeholder support for examiners. Officials in five of six selected states told us that limited stakeholder support for examiners and examiner programs, such as from hospitals and law enforcement, is a challenge to maintaining a supply of trained examiners. Some officials told us that hospitals may be reluctant to support examiners and examiner programs due to a low number of sexual assault cases treated each year. As a result, medical professionals may have to cover the cost of their examiner training courses themselves, including their travel and lodging expenses, and face lost wages associated with attending training. One official told us that hospitals may be reluctant to send nurses to examiner training as it takes away from their regular shift availability. Additionally, some hospitals do not pay examiners to be on-call. Officials in three states told us that hospitals typically either do not pay examiners to be on-call or pay on-call examiners significantly less than other on-call medical professionals. For example, one official in Wisconsin estimated that some examiners in their state receive between $1.00 and $1.50 per hour when on-call while others are not paid for on-call time. Officials from the American Hospital Association, when asked about whether they have developed any requirements, policies, or protocols concerning the training of or access to examiners in hospitals, told us that the association has not produced any information in this area. Apart from hospital support, officials in Colorado and Oregon explained that there is a need for more multidisciplinary support for examiners, such as increased law enforcement, prosecutor, and first responder understanding of examiners’ role. The literature we reviewed also shows that ambiguity around the role of the examiner in responding to sexual assault, may be a source of conflict between examiners and other professionals. For example, examiners were found to have experienced instances where victim advocates or law enforcement questioned examiners’ medical decisions, speed of evidence collection, or asked examiners to comment on the credibility of a victim’s case. One nationally representative survey of examiner programs found that examiner program coordinators felt that ongoing education of community stakeholders on sexual assault and examiner programs was needed due to high turnover in staff at relevant community institutions and agencies, such as law enforcement officers, victim advocates, and prosecutors. Through our interviews with officials, we learned of strategies that selected states have used to increase or mitigate limited stakeholder support for examiners and examiner programs. For example, officials in Colorado, Florida, Nebraska, Oregon, and Wisconsin told us that sexual assault response teams have been developed in their states to help community stakeholders to understand examiners’ role and better coordinate to meet the medical and legal needs of sexual assault victims. Further, a 2005 nationally representative survey of examiner program coordinators found that some programs addressed limited stakeholder support for examiner training by negotiating with employers to count training as paid work. Officials in Colorado also suggested that one strategy to mitigate limited hospital support for examiners would be to partner with non-hospital facilities such as health clinics that might support examiner programs. Low examiner retention rates. Officials in four of six selected states told us that low examiner retention rates can be an impediment to maintaining a supply of trained examiners. In addition to the challenges of limited training opportunities, technical assistance and other supportive resources, and stakeholder support for examiners, the physically and emotionally demanding nature of examiner work contributes to low examiner retention rates. Further, studies have indicated that dissatisfaction with compensation, long work hours, and lack of support, among other things, may contribute to examiner burnout. Examiners typically work on-call in addition to their full time jobs as, for example, emergency department nurses. Officials in Florida told us that examiners may be on-call for 6-hour, 12-hour, or even 24-hour shifts. Further, one survey of examiner programs in Maryland found that examiners were required to be on-call for an average of 159 hours per month. Wisconsin officials estimated that although 540 SANEs were trained over a 2-year period, only 42 (less than 8 percent) were still practicing in the state at the end of those 2 years. In addition, the 2005 survey of examiner program coordinators found that nearly two-thirds believed that examiner staffing, generally, was a challenge and nearly a third believed that SANE retention was a challenge. We provided a draft of this report to DOJ for review. DOJ provided technical comments that we incorporated as appropriate. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the appropriate congressional committees, the Attorney General of the United States, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or IritaniK@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. The following three tables show the number of grantees that used funding to provide training for examiners and the number of examiners who received training by federal grant program and state in 2013 and, where available, 2014. In addition to the contact named above, Kristi Peterson (Assistant Director), Leia Dickerson, Katherine Mack, Laurie Pachter, and Emily Wilson made key contributions to this report.

Summary: In 2013, about 285,000 individuals age 12 or older were reported victims of sexual assault, according to the Bureau of Justice Statistics. Studies have shown that exams performed by sexual assault forensic examiners—medical providers trained in collecting and preserving forensic evidence—may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates. Yet, concerns have been raised about the availability of examiners. The Violence Against Women Reauthorization Act of 2013 authorized funding for DOJ grant programs that can be used by states and other eligible entities, such as nonprofit organizations, to train and fund examiners. GAO was asked to review the availability of examiners nationwide. In this report, GAO describes (1) the prevalence and use of federal grants to train or fund sexual assault forensic examiners, (2) what is known about the availability of such examiners nationwide and in selected states, and (3) the challenges selected states face in maintaining a supply of examiners. GAO analyzed 2013 DOJ data on grantees' use of funding to train or fund examiners—the most recent full year of data available—and reviewed literature, relevant laws and DOJ documentation. GAO also interviewed grantees in six states selected based on several factors including population and geographic location, as well as DOJ officials, Department of Health and Human Services officials, and experts, such as health care association officials. Federal funding from three key Department of Justice (DOJ) grant programs can be used to train or fund sexual assault forensic examiners and for a range of other activities related to sexual assault, domestic violence, dating violence, and stalking. In 2013, at least one grantee in 49 states used such funds to provide training to examiners and at least one grantee in 26 states funded examiner positions. In 49 states, approximately 227 grantees or subgrantees—referred to collectively as grantees—reported providing training for over 6,000 examiners in 2013. The type of training examiners received ranged from comprehensive examiner training to training on specific topics, such as courtroom testimony. The extent of examiner training efforts supported with funds from the three DOJ grant programs varied by state. For example, in about half of the states, fewer than 100 examiners received training. In addition, in the states where at least one grantee funded examiner staff positions in 2013, grantees funded less than one position, on average. Approximately 75 grantees in 26 states funded roughly 50 full-time equivalent examiner positions in 2013. On the basis of literature GAO reviewed as well as interviews with experts and state officials, data on the number of examiners nationwide and in selected states are limited or unavailable. However, officials in all six selected states told GAO that the number of examiners available in their state did not meet the need for exams, especially in rural areas. For example, officials in Wisconsin explained that nearly half of all counties in the state do not have any examiners available. In health care facilities where examiners are available, they are typically available in hospitals on an on-call basis, though the number available varies by facility and may not provide enough capacity to offer examiner coverage 24 hours, 7 days a week. There are multiple challenges to maintaining a supply of examiners, according to interviews with officials in six selected states. These include: Limited availability of training . Officials in five of six selected states reported that the availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of trained examiners. Weak stakeholder support for examiners. Officials in five of six selected states reported that obtaining support from stakeholders, such as hospitals, was a challenge. For example, hospitals may be reluctant to cover the costs of training examiners or paying for examiners to be on-call. Low examiner retention rates. The above-mentioned and other challenges, including the emotional and physical demands on examiners, contribute to low examiner retention rates. Officials in one state estimated that while the state trained 540 examiners over a two-year period, only 42 of those examiners were still practicing in the state at the end of those 2 years. Officials described strategies that can help address these challenges, such as implementing web-based training courses, clinical practice labs, mentorship programs, and multidisciplinary teams that respond to cases of sexual assault. DOJ provided technical comments on a draft of this report, which GAO incorporated as appropriate.