Checklist of needs for clinical management of survivors of forced / unwanted sex


Purpose of checklist:
This checklist is designed to gather information on the extent to which health care facilities in Haiti have integrated attention to sexual
violence within their services in order to understand what the health
sector in this community needs to improve the health care response
to survivors of sexual violence at the community level.
This checklist tool is designed to assess needs,
not to evaluate the quality of care provided by
individual health facilities.

Definitions of sexual
As defined by the World Health Organization (WHO), sexual violence violence:
includes a broad range of penetrative and non-penetrative experiences, and many different types of coercion. However, this
data col ection focuses on any type of coerced sex, rape or assault
by any perpetrator (including husbands and intimate partners), as
described by the WHO as:

Physically forced or otherwise coerced penetration –
even if slight – of the vulva or anus, using a penis, other
body parts or an object. . . . other forms of assault
involving a sexual organ, including coerced contact
between the mouth and penis, vulva or anus.

How to use this checklist:
This checklist can be self-administered by someone working at a health facility or it can be completed by an external interviewer who
visits the health facility.
For all questions about supplies, private spaces, or medications,
please circle no or yes depending on whether or not they are
available in the facility. In addition, the person completing the
checklist has should check the column marked “√ = confirmed” if they
have personally seen that the supply, private space, or medication
is available. Otherwise, please leave this cell blank.
Sources of this checklist:
This checklist was adapted from several existing data col ection tools, and informed by: MSPP (2008) Manuel de Normes de Prise en Charge Clinique et Thérapeutique des Adultes et Adolescents vivant avec le VIH. Ministère de la Sante Publique et de la Population (MSPP), Port au Prince, Haiti. MSPP (2006) Fiche Technique : Prise en charge des victimes de violences sexuelles. Ministère de la Sante Publique et de la Population (MSPP), Port au Prince, Haiti. NEEDS ASSESSMENT CHECKLIST FOR CLINICAL MANAGEMENT OF SURVIVORS OF SEXUAL VIOLENCE
Name(s) and position(s) of respondent(s) PROTOCOLS: Does the health facility
Circle answer
√ = confirmed
(i.e. seen) by

Have a written protocol for caring for survivors of sexual violence in language of providers? Have a printed copy of the national Haitian protocol for caring for victims of sexual violence? PERSONNEL AND SERVICE PROVISION AT THIS FACILITY How many staff do you think have been trained to care for survivors of sexual violence?
Are female staff available during al operating hours to accompany survivors examined by What days, hours does this facility provide services for sexual violence survivors? Circle days: S M T W T F S
Approx. how many survivors of sexual violence seek services at this facility per month? PRIVACY: Do all examination spaces for survivors:
Circle answer
√ = confirmed
Provide complete visual privacy (i.e. patient cannot be seen from outside the space)? Provide complete auditory privacy (i.e. cannot be heard by anyone outside the space)? IF NO TO BOTH ABOVE: Do any exam spaces for survivors provide privacy?
SERVICES: Does the health facility offer the following services onsite:
Circle answer
If no, where

Post abortion care or abortion services (e.g. in case of danger to the mother’s life)? Testing for syphilis, gonorrhea, chlamydia, trichomoniasis, canchroid? Provision of post-exposure prophylaxis (PEP) of HIV per the national protocol? Provision of presumptive treatment for other STIs per the national protocol? 20 Access to lab facilities for all the services noted above? Provision of a medical certificate (attestation) for sexual violence (rape) survivors? Provision of a medical certificate for domestic violence (violence conjugale)? Provision of psychological services or support groups for survivors? Legal aid services (accompagnement légal)? SUPPLIES: Does the health facility have:
Circle answer
√ = confirmed
Soap and running water for hand washing? Forms to record case details and care provided, including pictograms to document injuries? A secure, lockable space for storing confidential records? An updated written list of referral services in the community (psychosocial, legal, etc.)? Supplies for col ecting forensic evidence? Supplies for universal precautions (gloves, safe disposal box, etc.)? Clean gowns (or something else) to cover survivors during examinations? Sanitary supplies (pads or local cloths)? Sterile instruments (kit)/ to repair tears? DRUGS LISTED IN THE NAT. PROTOCOLS: Does the health facility have:
Circle answer
√ = confirmed
Traitement des blessures:
D’Immunoglobuline humaine ou de SAT et Vaccin Antitétanique? Traitement / Prévention des IST :
Prévention de la grossesse :
COC contenant éthinylestradiol y lévonorgestrel (ou norgestrel) Neogrynon, Eugynon? COC contenant éthinylesstradiol et lévonorgestrel (ou norgestrel) Nordette, Lo-femenal? Copper-bearing intrauterine device (IUD) used for emergency contraception? Prophylaxie de l’infection au VIH:
Circle answer
Has this health facility had shortages of any supplies or drugs on this checklist in the past two NOTES: Please provide additional information about what this health facility needs to respond to sexual violence. ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________


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