This Web Site is a Work in Progress. If you have ideas about how we could make this more useful to health care practitioners, please Contact Us.  We will continue to improve this site. Visit us again soon to view new additions & improvements!

 

 

 

T o o l s  a n d  F o r m s
t o  D o w n l o a d

If there are tools and forms you would like to see here, let us know. We will try to find or create them. If you have helpful tools and forms to share with other health care practitioners, please send them to us. Contact Us

Contact List for VT Domestic and Sexual Violence Programs


Screen-Assess-Document Tool
Another version of a validated abuse screening/assessment tool is at http://endabuse.org/programs/healthcare/files/Consensus.pdf on page 39-40 in the document page numbers (it shows pages 47-48 on the computer display)


Assessment Tool
this has part of the screen –assess-document tool, without the screening questions but with more guidance on the assessment process


IPCV Combined Screening Tool
This was created by the Improving Prenatal Care in VT initiative of the VT Child Health Improvement Project. It is a psychosocial screen for pregnant women with detailed interview guides for intimate partner violence, depression and substance abuse. With small changes it could be adapted to other health care settings.

Domestic Violence Wallet Card
(for patients)

Sexual Violence Wallet Card
(for patients)

Safety Plan and Discharge Instructions

Consent to Photograph Form


The UC Davis Medical Training Center website has a page on
forensic photography tips: http://www.ucdmc.ucdavis.edu/
medtrng/domain/pdfs/Forensic
_Photography_Tips.pdf

For more information on Photo Documentation and Forensic Evidence Collection:

Family Violence Prevention Fund, National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings (Appendix K) http://endabuse.org/programs/healthcare/files/Consensus.pdf go to page 59 (computer count) or page 54 (page number in the document)/Appendix K. You can print the entire consensus guidelines or just that page.


Vermont Abuse Reporting Requirements


BCBS IPV Provider Guide
A booklet published by Blue Cross Blue Shield VT. General information on clinical response to IPV and some tools and forms in the appendices.


Also Check the National Consensus Guidelines  Comprehensive guidelines including forms and information sheets. A great resource for every health care setting.

  Hosted by the Vermont Medical Society