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.