Peace Corps Medical TG 510 Mental Health

Peace Corps
Technical Guideline 510
MENTAL HEALTH ASSESSMENT AND SUPPORT
1. PURPOSE
To guide Peace Corps Medical Officers (PCMOs) in mental healthcare best practices for
Peace Corps Volunteers.
2. BACKGROUND
PCMOs are Volunteers primary healthcare providers. In this capacity, PCMOs oversee and
must continuously evaluate a coordinated, Volunteer-centered program of medical and
mental healthcare.
Best practices in medical and mental health care is evidence-based practice. Evidence-
based medicine and mental health care is grounded in well-conducted, medical and
psychological treatment research, systematically reviewed, and often outlined in specific
clinical practice guidelines and practices algorithms published to help practitioners deliver
the best-known, evidence-based treatments to their patients (APA, 2006; Greiner, et al.,
2003; Sackett et al. 1996).
3. EVIDENCE-BASED PRACTICE
Evidence-based care is a multi-layered process (Figure 1). It promotes wellbeing by

integrating the best available research evidence, available resources (i.e., PCMO expertise),
with patients characteristics, values, culture, preferences and needs (APA, 2006; Greiner, et
al., 2003; Sackett et al. 1996). This process also considers the context of care (e.g., country,
local resources, etc.), and delivers services in a way compatible with the environment and
the organization within which problems occur and care is given (Greiner, et al., 2003).
3.1.Best available research evidence: Peace Corps Medical Officers are expected to
maintain up-to-date, current knowledge of research and clinical practice recommendations
and guidelines for medical and mental health. There are multiple ways to accomplish this
including attendance of Peace Corps-sponsored, or other, continuing medical education
conferences, professional journals, and consultation with Peace Corps Regional and
Headquarters medical and mental health staff. The following webs ites are also helpful:
http://www.uptodate.com/contents/search
http://www.cochrane.org/
http://www.ahrq.gov/
http://www.ebbp.org
3.2. Client/Population characteristics, needs, values, preferences and state of mind:

PCMOs must establish meaningful therapeutic relationships with all Volunteers starting at
Office of Health Services July 2015 Page 1

Pre-Service Training (PST). At the PST medical interview and at all subsequent patient
encounters, PCMOs will strive to understand Volunteers perspective on health and mental
healthcare along with their personalities, health and emotional strengths, needs, and
preferences. PCMOs skilled use of evidence-based assessment methods (see below,
Assessment of mental health needs) will augment knowledge developed in the doctor-
patient relationship, and facilitate evidence-based treatment planning.
To support PCMOs effective doctor-patient relationships with Volunteers, the COU staff
provide cross-cultural and communication skills trainings at CME and MOST conferences,
through webinars, and ad-hoc in consultations by phone and Lync. Examples in 2014 include
Trauma-Informed Care (MOST; CME), and Basics of Supportive Counseling (MOST).
3.3. Resources: Each Posts PCMOs have a unique set of clinical expertise and skills. At some
Posts around the world, this expertise is enhanced by the presence of Regional Medical
staff. For mild adjustment problems, Volunteer/Peer Support Network (V/PSN) programs
may also be helpful. Awareness of Medical Units strengths and limitations is critical when
determining a viable course of care for a Volunteer with mental health concerns.
3.4. Environmental and organizational context: For the US Peace Corps, context includes a
system of medical and mental health oversight from Headquarters (OHS) and Regional
Medical Officers as outlined in Technical Medical Guidelines, the availability and quality of
local medical and mental health resources (i.e., psychiatry, psycho-social therapy services),
national and regional phenomena such as proximity of Volunteer sites to care facilities,
transportation infrastructure, political stability or unrest, and other health or safety issues.
Because the US Peace Corps is a federal agency, the potential exists for US Congressional
input and inquiries of sentinel Volunteer health or mental health events.
Figure 1. Key elements of evidence-based care. (Spring, B. & Hitchcock, K., 2009)
Office of Health Services July 2015 2

3.5. Providing evidence-based patient care: Evidence-based care begins with developing a
plan with the patient that considers each aspect of the model (Figure 1).
The importance of each elements of the evidence-based model will differ at different times
in the care process, or depending on ones perspective. In developing an evidence-based
plan of care, providers consider patients needs together with other factors in the evidence-
based model. Patients input is a crucial to the entire process.
The Five As of Evidence-Based Care outlines how to translate evidence-based theory into
practice. PCMOs should consider the following when creating a plan of care for Volunteers
seeking help.
1. ASK enough questions about to the Volunteers problems, concerns, preferences, and
other factors affecting well-being so that you are clear about:
o the Volunteers definition of the problem and its impact on aspects of life
o the Volunteers ideas about the kind of help they want/anticipate
o other relevant information about need, kind, location, and timing of care
2. ACQUIRE additional, necessary information:
o Best available research findings on etiology and treatment of the specific
problem
o Resources (e.g., Medical unit resources/expertise; VSN)
o Contextual factors (e.g., OHS practices/policies relevant to specific problems;
availability of competent local professional care; country factors such as political
status, ease and safety of transportation between Volunteers site and Post)
3. APPRAISE evidence and information in terms of its applicability for the specific
Volunteer problem, and make the best choice that considers all the information:
o Please note: Care decisions at times may not equally honor each element of the
evidence-based practice model. It is important to help Volunteers understand
that care plans are continuously evaluated and adjusted accordingly.
4. APPLY elements based on steps 13, by doing the following, in this order:
o Outline care options
o Answer the Volunteers questions
o Make a collaborative decision for care that best accommodates
Volunteer concerns
best evidence,
resources, including PCMO expertise
care context (i.e., specific Peace Corps environment)
o Initiate treatment
5. ANALYZE and ADJUST:
o Evaluate treatment impact and changes in the Volunteers needs or priorities
o Alter aspects of care as needed.

4. PCMO RESPONSIBILITIES IN VOLUNTEER MENTAL HEALTH
4.1. PCMO responsibilities
PCMOs are responsible for the initial assessment of and first response to all Volunteers
mental health difficulties. This responsibility includes :
1. Managing acute psychiatric emergencies until the services of a licensed mental health
provider are secured, and care is fully transferred to that provider/facility (see TG 530)
2. Evidence-based assessment of Volunteers mental health difficulties
3. Mental health education and prevention of mental health problems
4. Short-term supportive counseling or stress management for common Peace Corps
adjustment stressors or problems (see, Common Peace Corps stressors, below)
5. Mental health referrals to licensed professional mental health providers incountry
and OHS/COU
6. Follow-up with in-country mental health services including review of documentation of
care provided to ensure progress and that standards of care are met
7. Ongoing care and support of Volunteers with medically accommodated mental health
conditions (e.g., psychotropic medication oversight)
4.2. Beyond the scope of PCMO responsibilities: mental illness/psychiatric diagnosis and
behavior problems
Mental illness, often labeled a psychiatric diagnosis, is a medical condition that disrupts a
person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as
diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often
result in a diminished capacity for coping with the ordinary demands of life. The symptoms
of mental illness are thoughts and feelings; the organ of focus is the brain.
PCMOs shall not diagnose or treat psychiatric disorders. The diagnosis and treatment of
mental illness/psychiatric diagnoses requires a licensed mental health professional.
PCMOs are frequently called upon to evaluate a Volunteer when Post staff or other
Volunteers observe and report problem behaviors. While behavior and verbal expressions
may reflect an individuals inner world, it is not true that all problems, behaviors, or
expressions indicate psychopathology or require psychological intervention.
Guidance to PCMOs regarding response to Volunteer behavioral problems is beyond the

scope of this document. Technical Guideline 520 on Substance Abuse does provide some
guidance on behavioral contracting in the case of substance abuse behaviors. When a
PCMO is unsure if a behavior problem warrants referral for psychological services, the
PCMO is advised to conduct an initial mental health assessment (see, Section 5). Request
for a COU evaluation may follow depending on the outcome of this process.

4.3. Management of psychiatric emergencies and other urgent mental health problems
The management of emergent and urgent mental health problems, such as psychiatric
emergencies, events that fall under Kate Puzey Act (KPA) jurisdiction (i.e., sexual assault) as
well as sequelae of other traumatic experiences, substance abuse-related problems, and
emotional issues related to acute medical issues are discussed in detail in separate
guidelines.
Referral procedures for psychiatric emergencies, legislated (i.e., KPA) and unique mental
health events as well as non-urgent psychological issues are outlined in the 2014 Proposed
Criteria for Mental Health Referrals to COU (below, Figure 2).
Because of the life threatening nature of psychiatric emergencies, steps for Volunteer care
are briefly outlined in Section 4.4. However, PCMOs are strongly encouraged to become
familiar with the detailed guidance provided in TG 530.
Detailed information for emergent, legislated events that involve unique mental health
issues can be found in the following Technical Guidelines:
Psychiatric Emergencies (TG 530)
Sexual Assault (TG 545)
Substance Abuse (TG 520)
Pregnancy (TG 170)
4.4. Psychiatric emergencies: In the case of psychiatric emergencies, PCMOs should

Provide medication to stabilize the Volunteer,
Provide continuous, close supervision until a licensed and appropriate mental health
professional assumes responsibility for the Volunteers care
Promptly contact OHS/COU for guidance.
5. EVIDENCE-BASED ASSESSMENT OF MENTAL HEALTH ISSUES
When conducted in a personalized and collaborative manner, mental health assessment is a

potentially therapeutic intervention (Katon et al. 2010; Riddle et al., 2002). Collaboratively and
carefully exploring the sources and meaning of a persons emotional distress oftentimes results
in symptom reductions (Clair & Prendergast, 1994; Levenson & Evans, 2000). Poston and
Hanson (2010) determined the assessment process itself has clinically meaningful and
measurable effects on the overall treatment process and outcomes.
Evidence-based assessment (EBA) emphasizes the use of research and theory to inform the
assessment process (Hunsley & Mash, 2007), and is necessary to prevent common assessment
errors (Garb, 2010; Wilkinson, T., 2014). Measurement-based care specifically enhances care in
several ways (Scott & Lewis 2015):
Provides important information about treatment needs and targets (i.e., focus of mental
health services)
Streamlines assessment process

Along with clinical judgment, it aides accuracy of assessment
Facilitates collaborative care between provider and patient, and among providers (i.e.,
results can be shared and discussed
When administered throughout a course of care, this process alerts all participants to a lack
of treatment progress.
Compared to physical health problems, emotional distress is uniquely dependent on language.

Culture also plays a key role in the communication of emotion. In short, all aspects of mental
healthcare are affected by language and culture.
Cultural and language differences are common between PCMOs and Volunteers. This fact of the
Peace Corps environment raises the risk of miscommunications or misunderstandings either of
which may impede access and delivery of appropriate mental health care. Evidence-based
assessment reduces that risk. The PROMIS-28 (see, Sections 5.15.2) is an integral part of
evidence-based mental health assessment (Attachment B). PCMOs are encouraged to
administer the PROMIS-28 and conduct assessments in person with Volunteers, whenever
possible.
Common assessment errors (Garb, 2010; Wilkinson, 2014)

Types of common assessment errors evidence-based assessments seeks to avoid include:
Patients reporting errors:
o Simple forgetting
o Recall bias i.e., errors resulting from differences in accuracy or completeness of
recollections (e.g., timing and/or frequency of a symptom)
o Pathological processes, such as PTSD avoidance (i.e., when discus sing personal history,
the deliberate omission of mentioning a past traumatic experience because doing so
arouses intolerable distress)
o Paucity of language to express certain concepts or feelings such as in alexithymia (i.e.,
inability to identify or describe emotions one feels )
Narrowness of clinical interview due to
o Lack of time
o Provider lack of experience or limited expertise in mental health issues
o Limited range in available measures of mental well -being
Common cognitive errors* Examples include:
o Confirmation bias (e.g., only noticing, or only collecting information, that supports a
particular diagnosis you have in mind)
o Availability bias (e.g., snap judgments)
o Aggregate fallacy (e.g., believing your patient is atypical, and your clinical knowledge is
atypical and exceptional, despite how aggregated data and conclusions evident in
clinical guidelines)
o Diagnosis momentum (e.g., perpetuating a diagnostic label already associated with a
patient without considering the validity of prior diagnosis or without critically
evaluating current information
o Representative error (e.g., it looks like PTSD, so it must be)
*All medical and mental health providers and assessors are at risk for making such errors.
Awareness of common cognitive errors and the use of tools that circumvent such errors are key to
their prevention.
Figure 2. Common assessment errors evidence-based assessments (EBA) seeks to avoid

5.1. PROMIS Background
The PROMIS-28 is an integral part of evidence-based mental health assessment.

PROMIS is an acronym for: Patient-Reported Outcomes Measurement Information System.
PROMIS is a 21st century initiative of US National Institutes of Health (NIH) supported by funds
from the US Department of Health and Human Services. The goal of this initiative is to improve
patient health and mental healthcare by improving and standardizing patient outcomes
measurement tools in research and clinical practice.
PROMIS surveys assess disease and wellbeing constructs with greater precision and sensitivity
than legacy measures (e.g., Beck Depression Inventory). Because PROMIS questions measure
problems more precisely, fewer questions are needed; shorter surveys reduce patient
burden. PROMIS tools are free, and have the capability to be used through computer
adaptive testing. It is anticipated that broad adoption of PROMIS tools will refine knowledge of
patient outcomes resulting from systematic reviews of research and clinical care where
assessments all use the same PROMIS language.
5.2. PROMIS-28
PROMIS-28 redacted for Peace Corps (PROMIS-28) is derived from PROMIS 29 a US National
Institutes for Health (NIH) product. PROMIS-28 incorporates two improvements: it makes paper
and pencil scoring easier, and omits a pain intensity item, Item 29, not part to norming data .
In brief, PROMIS-28 as a paper/pencil survey is easier to use, while retaining all norming
comparability as the original PROMIS 29. Peace Corps adopted PROMIS-28 in 2014 as an
evidence-based way to assess mental wellbeing, and identify need of mental health care.
PROMIS-28 assesses health-related quality of life by inquiring into functioning in seven (7)
domains. These areas/domains of functioning are: physical functioning, anxiety, depression,
fatigue, sleep quality, social functioning, and pain.
PROMIS-28 uses T-Scores and is normed against US 2000 Census non-treatment-seeking adults.
Its results provide a profile of wellbeing.
PROMIS-28 T-scores are calculated for each domain, and these results show how well a person
is functioning compared to the US general population in that domain.
Results easily identify when an individuals problem in a particular domain exceeds that seen in
most US adults, thus warranting further evaluation.
The PROMIS-28 should be used in all assessments of non-urgent Volunteer mental health
problems. Although its scope is broad, PROMIS-28 takes only 510 minutes to complete.

5.3. PROMIS-28: Scoring and interpreting
Scoring: Simple raw scores for each domain are summed. Domain totals are used to find T-
scores on an accompanying table.
Interpreting scores: The T-score metric is anchored to a distribution of scores normed against
the US general, adult population (mean = 50; standard deviation = 10). Interpreting T-scores is
fairly simple: higher scores (T-score = 60) for negative domains, such as anxiety, mean worse
functioning: more anxiety is worse. However, for positive domains such as social ability, a
higher T-score means better functioning: greater social abilities are better!
The PROMIS-28 measure itself and additional information about scoring and interpreting are
available as an attachment to this guideline on the Peace Corps Intranet (Attachment C).
5.4. The mental status examination
All assessments of emotional distress and referrals to licensed mental health professional
whether in-country or to OHS/COU should include a mental status examination. The Mental
Status Examination (Attachment A) is a consistent, objective means of evaluating and recording
the mental status. This tool should be a routine part of a complete evaluation of any mental
health problem.
6. PREVENTION OF MENTAL HEALTH PROBLEMS
The PCMOs responsibilities for preventing mental health problems during Peace Corps service
begin in Pre-Service Training (PST). Teaching the PST health and mental health training modules
and conducting individual interviews, the PCMO should strive to establish a personal and
sustained rapport with Volunteers.
Three (3) tools are available to help PCMOs assess Volunteer resilience and vulnerability
starting at PST. These tools are The Personal Health Action Plan (PHAP), the Alcohol Use
Disorders Identification Test (AUDIT), and the Patient Reported Outcomes Measurement
Information System schedule 28 (PROMIS-28). All are attached to TG 510 in the appendix, and
their uses are described as follows:
6.1.The Personal Health Action Plan (PHAP):
The PHAP: The PHAP is a multi-page dynamic plan for Volunteer resilience during Peace Corps
service. Developed in fall 2013 by PCMOs for OHS as part of improving Volunteer mental health
pre-service training (PST), PHAP asks Volunteers to take an active role in maintaining mental
and physical wellbeing during Peace Corps service. As a dynamic plan for resilience, it may be
updated at designated intervals (e.g., IST, MST). It should also be reviewed and revised in
consultation with the PCMO as issues or need arise.
a) The PHAP is introduced at the medical portion of PST presented by the PCMO.
b) Volunteers must sign as a health plan contract/agreement before swearing in.
c) PCMOs are encouraged to:
i. review each Volunteers PHAP,
ii. consider other relevant information (e.g., pre-service medical and mental health
history; observations of the Volunteer; PROMIS-28 and AUDIT results),
iii. identify any concerns with any Volunteer, and work collaboratively with each of the
identified Volunteers to discuss and if needed revise the PHAP before signing, before
Volunteer is sworn in.
d) PCMOs shall refer to the PHAP whenever administering providing supportive counseling to
Volunteers.
e) PCMOs shall work with Volunteers to revise the PHAP during service if/when Volunteer
needs and issues arise.
6.2.The Alcohol Use Disorders Identification Test (AUDIT):
The AUDIT: The AUDIT is a simple ten-question test developed by the World Health
Organization to determine if a persons alcohol consumption may be harmful. For convenience,
it is attached to this guideline (Attachment 5).
During PST, OHS asks PCMOs to have each Volunteer complete an AUDIT, and to discuss AUDIT
results individually during the PST medical interview.
For more detailed information about the AUDIT, see TG 520.
6.3.The Patient Reported Outcomes Measurement Information System (PROMIS-28)
The PROMIS-28: The brevity of this mental health assessment tool is perfect for obtaining a
quality of life profile for each Volunteer at PST, MST, at times of problems, and at COS.
PROMIS-28 results can help guide individual resilience plans such as that developed using the
PHAP and can help gauge progress towards greater resilience in the Peace Corps
environment.
6.4.Additional prevention topics
Starting at PST, PCMOs may take the opportunity during each encounter with Volunteers to
discuss other issues or topics that may augment health and wellbeing, such as:
Volunteers understanding of country safety and security issues

Being involved in publishing and/or reading Volunteer initiated newsletters
Knowledge of the Posts emergency evacuation plans
Awareness of assistance available through Posts Volunteer/Peer Support Network (V/PSN)
The electronic pamphlet, A Few Minor Adjustments, (listed among the references at the end
of this TG) provides additional material concerning Volunteer adjustment issues in Peace Corps
service.

7. PCMO SUPPORTIVE COUNSELING
All Volunteers are challenged in multiple ways as they adjust to the Peace Corps environment
and service. PCMOs are expected to provide short-term supportive counseling Volunteers for
common adjustment problems, normal grief reactions, and questions about Early Termination
of service.
A complete review of short-term supportive counseling techniques and issues is beyond the
scope of this guideline. But a complete discussion is contained in Attachment 6.
7.1.Distinguishing common adjustment problems from mental illness/ adjustment disorders
All Volunteers are challenged in multiple ways as they adjust to the Peace Corps environment.
It is important for PCMOs to help Volunteers identify and understand the sources of stress in
their lives.
Common adjustment stressors in Peace Corps include:
1. Loss of ready access to HOR family, friends, community, lifestyle, amenities

2. Personal safety fears
3. Loneliness
4. Lack of language proficiency resulting in communications problems
5. Stringent Peace Corps and Post policies related to alcohol use and travel
6. Feelings of inadequacy stemming from a sense of lack of sufficient social, communication
and/or professional skills for Peace Corps life/work
7. Cross-cultural stress resulting from daily exposure to different social, ethical, and cultural
values (e.g., lack of accustomed degree of privacy/personal space; acceptance of corporal
punishment of children in some cultures; misogyny/gender-based harassment)
8. Un-met expectations related to Peace Corps work, such as unstructured job responsibilities,
and/or in-country living conditions
9. Unrealistic achievement expectations
10. Work conflicts: with CP, supervisors, site mates or co-workers
11. Social pressures, such as pressure to drink alcohol, do drugs or have sex, or gossip among
PCV community
As PCMOs consider starting supportive counseling they should explore several factors related to
the onset of the current problem and distress:
Precipitant: How and when did it start?
Persistence: How long have you been upset about it?
Severity: On a 05 scale, how bad is it most days?
Impact: Does it affect your work? your sleep? .your relationships?
Administering a PROMIS-28 may help both PCMO and Volunteer consider whether the severity
of the distress might fall in a normal realm compared to everyday American adults.

PCMOs may also consider the DSM-5 criteria for Adjustment Disorders to distinguish common
adjustment problems from this gateway psychiatric disorder.
Criteria for Adjustment Disorders, in brief, are:

1. Identifiable stressor;
2. Timing: Distress begins within 3 months of stressor, but not more than 6 months after
stressor, or the consequences of the stressor, have ended;
3. Clinically significant distress: Distress is defined as out of proportion to the severity or
intensity of the stressor and/or significant impairment in important areas of
functioning most notably, social and/or work-life
4. Not caused by bereavement.
In summary, considering onset, severity, and nature of a Volunteers problem, obtaining a

profile of wellbeing using PROMIS-28, and comparing this information with criteria for DSM-5
Adjustment Disorders (see Attachment D) will help PCMO decide whether or not supportive
counseling could help, or if it may be more expeditious to prepare a mental health referral.
7.2.PCMO-provided supportive counseling for Volunteer adjustment issues
Supportive counseling expected of PCMOs is distinct from counseling or therapy provided

by a professional mental health therapist as follows:
Professional mental health treatment by licensed professionals is a prescribed course of

psychotherapeutic care based on psychiatric assessment including diagnosis, assessment of
risk, and conceptualization of maladaptive mechanisms contributing to and/or maintaining
symptoms and problem behaviors. A course of professional mental health treatment is
intended to resolve symptoms consistent with identified psychiatric diagnosis and facilitate the
Volunteers adoption of more adaptive responses to problem-triggering situations.
Professional mental health treatment for Peace Corps is often a relatively short course of care
(e.g., 46 sessions). However, a longer course of care (e.g., 1520 sessions) may be indicated.
Length-of-care decisions are based on the Volunteers needs, diagnosis, and clinical practice
guidelines regarding the evidence-based treatment for a specific mental health condition. This
determination is made by a licensed mental health professional.
Please note: Although in-country licensed mental health professional may determine a longer
course of care is warranted, in-country mental health services is limited to a maximum of 46
therapy sessions per Volunteer tour of Peace Corps service.
Supportive counseling that PCMOs are expected to provide is short-term, one to four sessions.
In brief supportive counseling PCMOs are expected to help Volunteers to identify and alleviate
temporary emotional problems related to adjusting to Peace Corps (e.g., worries,
misunderstandings, frustration, mild problems with low mood or lack of motivation.) The
PCMO is expected to do this in a supportive and empathetic manner.

The temporary nature of common adjustment problems and mild severity of distress is
important to consider. Such defining characteristics (i.e., temporary, mild) enable a brief course
of supportive counseling to be effective. Problems that exceed that time frame, or problems
and distress that do not respond to supportive, empathetic care may indicate the need for
professional mental health intervention.
7.3. Integrating supportive counseling with evidence-based assessment and prevention of

mental health problems
Supportive counseling consists of active listening and basic, problem-solving methods. Together
these strategies are intended to help the PCMO help the Volunteer identify the problem and
potential solutions.
After identifying the problem, the PCMO should discuss with the Volunteer:
How the Volunteer addressed this issue on the Personal Health Action Plan (PHAP)?
What coping strategies the Volunteer is using?
Available social supports
As solutions or alternative coping methods are identified, the PCMO and Volunteer should
incorporate this into the Volunteers PHAP.
Initial and follow-up administration of the PROMIS-28 (e.g., after 23 counseling sessions) can
augment short-term supportive counseling efforts by:
1. Normalizing distress
2. Focusing supportive counseling efforts: PCMO and Volunteer may agree to explore domains
of functioning identified on PROMIS-28 that are worse than the norm
3. Quantifying distress for purposes of determining if supportive counseling or suggestions for
stress management are helping
4. Determining when a referral to professional mental health is needed (see section 7.4).
Detailed information about the PROMIS-28 is in section 5 of this document.
7.4. When short-term supportive counseling by the PCMO is not enough
A short course of supportive counseling should be sufficient to address most common

Volunteer problems. The following two situations are indicators professional psychological care
may be needed are:
1. Failure to resolve worries, frustrations, and mild problems with low mood or motivation
after a few (one to four) supportive counseling sessions over a few weeks time as
evidenced by, for example:
a. PROMIS-28 scores remain elevated and unchanged
b. Subjective assessment by PCMO and Volunteer that problems are unchanged
c. The impact of problems on social and work functioning is worsening
2. Volunteer is unable to participate effectively in supportive counseling:
a. Volunteer has a bias against discussing emotional problems with an HCN,
b. Volunteer is uncomfortable and therefore unable to discuss private problems with
someone not of the same gender, race, religion, sexual preference, or other
important identifying characteristic as the Volunteer.
A more detailed outline for considering referrals for the help of a licensed mental health
professional in the case of non-urgent mental health problems is found in Section 8, Figure 2.
(below): 2014 Proposed Criteria for Mental Health Referrals to OHS/COU.
7.5. Confidentiality:
Confidentiality is as important in supportive counseling as in other kinds of medical care.

Because Volunteers are part of a closely knit community, concerns about privacy and
confidentiality are always present.
Many Peace Corps Posts function as a closely knit community too. Disclosure of medical and
mental health information about Volunteers, and access to Volunteers personal health
information and medical record may only be shared among licensed medical and mental health
Peace Corps professionals, and outside contracted and licensed medical/mental health
providers when contracted to provide care to a specific Volunteer for specified conditions.
Please note: Except as needed for billing and reimbursement for contracted medical and mental
health services, medical and mental health confidentiality shall not be shared with any non-
medical/mental health or non-licensed persons, including Peace Corps administrative personnel,
except for the purpose of preventing harm in the case when a Volunteer is at risk of harm to self
or others.
Whether seeking supportive or professional counseling, Volunteers must be assured their
sessions will be kept in the strictest medical confidence. Ways to help ensure a Volunteers
right to confidentiality are:
Keep all documentation related to a Volunteers health problems confidential
Avoid discussing a Volunteers health condition with other PC staff
Discuss problems related to the Volunteers mental health care with medical support staff
only when necessary for the performance of their duties.
7.6. Limits of confidentiality:
The sharing of medically confidential information is appropriate when the Volunteer

presents a physical danger to him/herself or others (e.g., suicidal ideation, homicidal
ideation) or when the Volunteer is physically unable to care for himself/herself. Instances
of physical or sexual assault must always be brought to the attention of the Country
Director (see Technical Guidelines 150 Medical Confidentiality and 420 Assault
Notification and Surveillance System.) unless the Volunteer has opted for restricted
reporting. In addition, the PCMO may contact COU for guidance on confidentiality. In some
instances, the Office of the Inspector General (OIG) must also be notified.

8. MENTAL HEALTH REFERRALS TO OHS/COU
Criteria for making mental health referrals to OHS/COU are outlined in the box on page 15,
Figure 2.
They include guidance on addressing emergent and legislated or other traumatic events, and
guidance for referring non-urgent and other unique mental health issues. PCMOs
should use this multi-step process when considering any referral to OHS/COU.

Proposed 2014 Mental Health Referral Criteria to COU
PCMOs s ha ll refer Volunteers to a licensed mental health professional at Peace Corps Headquarters Counseling
a nd Outreach office when
A. Vol unteers psychological well-being is brought to the PCMOs a ttention either by s elf-referral, as a result
of s elf-disclosure of difficulties during a physical exam or other routine medical clinic a ppointment, or
through expressions of concerns by others (fellow PCVs , s taff, etc.). AND B, C, or D
B. Vol unteers psychological difficulties include ANY ONE of the following:

a . Sui cidal i deation, plans or intentions;
b. Homi cidal ideation, plans or i ntentions;
c. Sel f-harm behavi ors (e.g., cutting, burning) or high health risk behaviors (e.g., underweight a nd
fa i lure to eat sufficient calories);
d. Ps ychoti c symptoms;
C. The Vol unteer i s a vi ctim of a sexual assault as defined in IPS 3-13 and ANY ONE of the following:
a . In the i mmediate aftermath of a n assault:
i . The PCMO wa nts assistance assessing the s everity of emotional distress and mental
hea lth needs of the Volunteer;
ii . The Vol unteer requests contact with a licensed professional to discuss reactions to the
i nci dent a nd/or to discuss options for mental health ca re;
iii. The Vol unteer requests mental health counseling to help manage distress related to
the i ncident;
b. Duri ng the one-month follow-up medical consultation with a Volunteer/sexual a ssault s urvivor
a grees to a consult by COU a fter he/she:
i . Screens positive for PTSD using the PC-PTSD;
ii . Reports ongoing a nd/or i ncreasing distress since the i ncident i nterfering with
functi oning;
iii. Acknowledges poor coping (e.g., a dmits to increasing alcohol use, social isolation, etc.)
ei ther s pontaneously or i n response to questions
c. At a ny ti me a sexual assault survivor/Volunteer discloses emotional distress or dysfunction that
ma y be related to the assault a nd wishes to s peak with a licensed mental health professional.
D. After s upportive counseling by the PCMO, the Volunteer continues to be distressed and AT LEAST TWO (2)
of the following:
a . As s essment of s ymptoms AND results on PROMIS 28:
i . Symptoms of emotional distress in one psychiatric domain a re of moderate severity
(i .e., more than 1 SD di fferent from norm);
ii . Symptoms of emotional distress in two or more domains a re mild (wi thin 1 SD of
norm) on PROMIS 28, at least one of which perta ins to psychological i ssues;
b. Dys function:
i . Symptoms i nterfere with Volunteers ability to work, get along s ocially, or ca re for s elf;
ii . Di s ordered eating or s ubstance a buse that interferes with functioning;
c. Pre-s ervice history of mental i llness:
i . Vol unteer has a pre-service history of mental illness a nd treatment, AND current
probl ems may represent a new episode, or worsening, of a pre-existing problem;
d. Di a gnostic uncertainty by the PCMO;
e. Two (2) of the following:
i . The PCMO ha s l ow confidence regarding a bility to treat or manage the Volunteer i n
country;
ii . The Vol unteer will not a ccept continued mental health ca re from PCMO, or from a n in-
country/HCN mental health professional;
iii. The Vol unteers i nterpersonal behaviors interfere with, or otherwise undermine,
trea tment available from PCMOs or i n-country provi ders.
Figure 2. 2014 Proposed Criteria for Mental Health Referrals to OHS/COU

8.1: Mental health referral report:
In all cases PCMO should document supportive counseling care and any other case information
accurately. When making a mental health referral, PCMOs should include a description of
supportive care and any other pertinent case information along with a personal impression of
the problem. The PCMOs report is important information. This collateral information helps
licensed mental health professionals assess the mental health of the Volunteer and accurately
diagnose the problem.
An outline for the PCMO mental health evaluation and report that should accompany mental
health referral to OHS/COU is provided on page 17, Figure 3.
Whether referring the Volunteer to a mental health professional (in-country clinician, COU or
medevac to COU) along with the mental health evaluation and report, the PCMOs referral
letter should include:
A brief summary of Volunteers view of problem.

A brief summary of PCMOs view of problem.
Information on the duration and severity of the problem.
Current medical conditions and treatments
Information on the Volunteers attitude about counseling
Any information about Volunteers diagnosis and prior treatment

ELEMENTS OF MENTAL HEALTH EVALUATION & REFERRAL REPORT
SUBJECTIVE
Current condition
The following types of questions will generally help to identify the nature of the problem:
What brought you in today? How are you adapting?
How are things at work? Your site? Your housing? Your Host family?
What is your relationship like with peers, supervisors, and co-workers?
What is it like for you to be a Volunteer living at your site?
What and how often do you hear from home?
Manifestations of stress reactions, and common adjustment problems :
Tears Anger out of proportion to the situation
Anxiety Unreasonable demands
Apathy Confusion
Disheveled appearance or significant weight change
Past history
Medical, psychiatric, drug/alcohol use
Family history of psychiatric illness
Social historydivorce, abuse, etc.
Work history
OBJECTIVE
Examination
Changes in mental health can be due to medical illness (e.g., infection, disease, drug or alcohol
use) or psychiatric illness. Objective measures of both are indicated and important to
differential diagnosis:
A mental status examination (ATTACHMENT A)
PROMIS28 results in the form of T-scores (see Attachment 1)
A physical examination with special regard to:
vital signs, temperature, weight change
evidence of trauma (head injury) or infection
evidence of drug use or intoxication
Laboratory screening tests
If an underlying medical illness is suspected, medical tests may be indicated: E.g.,
CBC with differential Blood glucose
Urinalysis Liver and renal function tests
Electrolytes Thyroid function
Malarial smear Toxicology screen
Figure 3. Details that comprise PCMOs mental health referral report to OHS/COU
9. IN COUNTRY MANAGEMENT OF NON-URGENT MENTAL HEALTH PROBLEMS
9.1. Using licensed mental health providers in country:
PCMOs are responsible for identifying competent, licensed mental health professionals in
country, and initiating contracting with in-country providers. This process includes:
Clarifying Peace Corps requirements for contracting providers, and
Overseeing, and evaluating effectiveness of in-country mental healthcare provided to
Volunteers

PCMOs should take care to advise in-country provider regarding Peace Corps requirements
with regard to documentation and the limits of patient-provider confidentiality. Specifically,
PCMOs should ensure the provider agrees with:
Peace Corps requirement that providers inform Peace Corps in the case of suicidal,
homicidal or self-harm intention, plans or attempts, and in the case where a Volunteer
discloses he/she was a victim of sexual assault
Peace Corps documentation requirements
PCMOs should make a viable plan for obtaining treatment notes from in-country providers.
Provision of treatment notes is not negotiable. It is a requirement of the contract between in-
country mental health providers and the US Peace Corps. In-country providers who do not
fulfill this provision of the contract for care will lose status as contractual providers for the US
Peace Corps.
PCMOs should plan follow-up discussions with Volunteers referred to in-country providers to
obtain Volunteer feedback both in the form of anecdotal reports of quality of care, but also
patient-reported outcomes information (i.e., PROMIS-28 results). Feedback allows PCMOs to
track quality and standards of care of the in-country mental health services to which Volunteer
are referred.
9.2. Psychotropic medication management:
Psychotropic medications are commonly prescribed to treat a variety of psychiatric s ymptoms

and have been proven to be both safe and effective in many circumstances. One must always
balance the potential risks associated with these medication with the potential benefits. Peace
Corps service is full of challenges, and Peace Corps Volunteers often experience temporary
difficulties adjusting to new challenges. Psychotropic medications are rarely indicated for these
types of temporary symptoms. Many volunteers enter Peace Corps service on a psychotropic
medication regimen. Medical accommodation for these PVS is based on a history of stability on
a specific medication regimen and the role of the PCMO or Peace Corps consultant is to monitor
the PCV and their medication regimen during their service. Changes in these medication
regimens should only be done after consultation with OMS and COU.
PCVs may ask for psychotropic medications during their service. Please follow the guidelines
below for the use and management of psychotropic medications in PCVs.
Prior history of use of psychotropics: If a PCV has a documented past history of effective
treatment and tolerability on a specific agent, psychotropic medication may be started and
titrated for uncomplicated mood and anxiety symptoms utilizing an approved SSRI
(sertraline, fluoxetine, escitalopram, etc.), SNRI (venlafaxine) or buproprion. Medication
dose may be titrated up to 75% of FDA recommended maximum dose, or up to 100% of
maximum dose if the pre-service records show that dose was tolerated and effective.
PCMO should notify OMS and COU for informational purposes.
No prior history of use of psychotropics: In a PCV who does not have a past history of
treatment with psychotropic medication, psychotropic medication may be started and
titrated for new onset uncomplicated mood and anxiety symptoms only after a consultation
with OMS and COU utilizing an approved SSRI, SNRI or buproprion when clinically indicated.
Acute anxiety: Short term use of benzodiazepines for acute anxiety may be initiated as
indicated In TG 530 Psych Emergencies. (TG 530, Sec 6 Acute Anxiety A short course of a
minor tranquilizer may alleviate the problem. This treatment should not be extended for
more than a week, at which time the dosage should be tapered by giving the night-time
dose only for several days. If there is no improvement or there is an ongoing need for
anxiolytics, discuss the patients condition with OMS/ RMO and COU). Research shows
that use of benzodiazepines for greater than two weeks for post traumatic anxiety increases
the risk for development of Post-Traumatic Stress Disorder (Guina, J, et al, 2015).
Alprazolam should be avoided as it is associated with more inter-dose anxiety, as effects can
wear off rapidly in some patients, causing more anxiety before the next dose (Cloos JM &
Ferreira V, Curr Opinion Psychiatry, 2009). When alprazolams faster onset of action is
combined with its short half-life, these effects can strongly reinforce pill-taking to alleviate
anxiety, can enhance potential for abuse, and may reduce self-efficacy (i.e., patients
confidence that they can manage their anxiety on their own) (Herman JB, Rosenbaum JF,
Brotman AW, 1987). Benzodiazepines should be avoided in individuals engaging in Cognitive
Behavioral Therapy as they have been shown to reduce the efficacy of CBT (Westra HA,
Stewart SH, Teehan M, Johl K, Dozois DJA, Hill, 2004.)
Sleep difficulties:
o Short term use (one to two weeks) of sedative/hypnotics for insomnia may be
initiated when clinically indicated after a consultation with OMS and COU. Non-
benzodiazepine medications are preferred due to less risk for tolerance and
dependence (Buscemi N, et al, 2007.)(CITATION).
o Long term use (greater than two weeks) of sedative/hypnotics for insomnia should
be avoided (Kripke, DF, et al, 2012.) (CITATION) and if symptoms persist consult
with OMS and COU.
o
Adding psychotropics to an established regimen: Augmentation with a second
psychotropic medication should only be initiated after consultation with OMS and COU.
Initiation of antipsychotics: Except in emergency situations, as covered in TG 530

Psychiatric Emergencies, antipsychotic medication may only be started after consultation
with OMS and COU. This class of medications is primarily indicated for acute agitation,
psychosis and acute mood symptoms, which all constitute potential psychiatric emergencies
and should be treated as such. Initiation of longer term maintenance use or off label use of
antipsychotic medications is not supported.
Mood stabilizers: Mood stabilizers should be reserved for the stabilization of acute mood
symptoms with thorough evaluation and clear clinical indication. This should only be
considered after a consultation with OMS and COU if a PCV is under direct psychiatric care
and needs stabilization for medical evacuation. Mood stabilizers are used primarily
indicated for the treatment of Bipolar Spectrum Disorders and the diagnosis and treatment

of these disorders should not be undertaken with PCVs while at Post. Initiation of longer
term maintenance use or off label use of mood stabilizing medications is not supported.
Stimulants :
o Stimulant medication for the treatment of ADHD may be initiated and titrated for a
PCV who has a history of ADHD documented in their preservice medical record.
Starting dose should be the FDA recommended starting dose of the ADHD
medication in question. Dose may be titrated to the maximum dose used in the past
as documented in the preservice record. PCMO should notify OMS and COU for
informational purposes. If the PCV requests treatment with a higher medication
dose or a different medication a consultation with OMS and COU is indicated.
o Stimulant medication for the treatment of ADHD may not be initiated for a PCV who
does not have a documented history of ADHD. If requested by a PCV a consultation
with OMS and COU is indicated. For OMS to consider starting ADHD meds on a PVC
without a disclosed history of ADHD treatment, we would need clear clinical
evidence that they were experiencing ADHD symptoms as well as recent preservice
documentation (within the past 3 years) from a licensed mental health provider,
usually a psychiatrist or psychologist, that included a thorough evaluation and clear
diagnosis of ADHD.
o Stimulant medication may be effective in the treatment of ADHD, but has a high
potential for abuse and dependence. Treatment of ADHD may provide benefit but
does not constitute an emergency situation.
9.3. Other mental health management issues:
Finally, PCMOs are responsible for the following:
Communicating/consulting with OHS/COU on Volunteer mental health concerns

Understanding mental health referral guidelines for OHS/COU
However, PCMOs should take note that at all times OHS and COU staff are available to assist
with evaluation and support in mental health cases. And, OHS and COU ask that PCMOs work
closely and consult with OHS/COU in all cases of psychiatric emergency, but also when short-
term counseling is not successful in relieving the Volunteers distress.
9.4 Mental healthcare and the medical record
A copy of any field consult/mental health referral from the PCMOs is maintained in the Health
Record.

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Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T.P. &
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Opinions in Psychiatry; 22(1):9095.
Counseling and Outreach Unit. Trauma-informed care. Presentations at Peace Corps

Continuing Medical Education Conferences, and at Medical Officer Staff Trainings, 2013 and
2014.
Garb, H. N. (2010). Clinical judgment and the influence of screening on decision making. In, A. J.
Mitchell and J. C. Coyne (Eds.) Screening for Depression in Clinical Practice: An Evidence-Based
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Guna, J., Rossetter, S. R., DeRhodes, B. J., Nahhas, R.W. & Welton, R. S. (2015). Benzodiazepines
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therapeutic intervention. Psychological Assessment, 22, 203212.
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Medical Education Conferences, August/September 2014. Pre-Service Volunteer Health
Trainings

TG 510/530 ATTACHMENT A
MENTAL STATUS EXAMINATION
Appearance: neat/groomed/appropriate dress casual sloppy poor hygiene

underweight overweight poorly nourished
other
Behavior: cooperative relaxed agitated uncooperative aggressive suspicious

guarded preoccupied withdrawn evasive bizarre
other
Speech: normal soft mumbled loud slurred hostile pressured

other
Mood: (ask patient how she/he has been feeling lately)
Affect: restricted cold flat superficial labile silly apathetic ambivalent tense
anxious apprehensive worried afraid panicked angry enraged ecstatic
euphoric irritable sad depressed hopeless worthless
other
Suicidal [ ] thoughts [ ] plans [ ] actions

Describe:
Homicidal [ ] thoughts [ ] plans [ ] actions

Describe:
Thought processes: goal-directed tangential vague repeats self illogical

flight of ideas poverty of speech loose associations neologisms
Thought content:
Hallucinations: olfactory tactile visual auditory gustatory
Delusions: control persecution sexual grandeur religious somatic
Perceptions: magical thinking depersonalization phobias
obsessive thoughts compulsive behaviors
Orientation: person place time

Consciousness: clear clouded delirious comatose drowsy intoxicated
Memory: immediate events recent events remote events
Attention span: normal slightly distractable moderately distractable very distractable
Insight: good adequate poor
Judgment: good adequate poor
General knowledge: intact impaired
Functional impairments: (if any, relative to work and to daily activities)

*PROMIS-28for The Peace Corps
Volunteer name: DOB: Id #:
Instructions: Please respond to each question or statement by marking ONE box per row
No A little Some With much Unable
Physical functioning difficulty difficulty difficulty difficulty to do
Currently
1 Are you able to do chores such as 5 4 3 2 1
sweeping, yard work, mopping floors?
2. are you able to go up and down stairs at 5 4 3 2 1
a normal pace?
3. are you able to go for a walk of at least 5 4 3 2 1
15 minutes?
4. Are you able to run errands and shop? 5 4 3 2 1
Anxiety Never Rarely Sometimes Often Always
In the past 7 days.
5. I felt fearful 1 2 3 4 5
6. I found it hard to focus on anything 1 2 3 4 5
other than my anxiety
7. My worries overwhelmed me 1 2 3 4 5
8. I felt uneasy 1 2 3 4 5
Depression Never Rarely Sometimes Often Always
In the past 7 days.
9. I felt worthless 1 2 3 4 5
10. I felt helpless 1 2 3 4 5
11. I felt depressed 1 2 3 4 5
12. I felt hopeless 1 2 3 4 5
Not at all A little bit Somewhat Quite a bit Very
Fatigue much
During the past 7 days.
13. I feel fatigued. 1 2 3 4 5
14. I have trouble starting things because I 1 2 3 4 5
am tired.
15. How run-down did you feel on 1 2 3 4 5
average?
16. How fatigued were you on average? 1 2 3 4 5
Very poor Poor Fair Good Very
Sleep disturbance good
In the past 7 days.
17. My sleep quality was 5 4 3 2 1
*PROMIS-28 is a redacted version of PROMIS29. Redaction adds raw score values into domain cells, and adds a scoring
table. It omits item 29 Pain intensity. The last change does not affect comparability of PROMIS 28 T-scores w/ population norms
for the Pain domain; item #29 was not included in original PROMIS29 profile calculations.
*PROMIS-28for The Peace Corps
Volunteer name: DOB: Id #:
Sleep disturbance, continued much
18. My sleep was refreshing 5 4 3 2 1
19. I had a problem with my sleep 1 2 3 4 5
20. I had difficulty falling asleep 1 2 3 4 5
Ability to participate in social Never Rarely Sometimes Usually Always
roles and activities
21. I have trouble doing all of my regular 5 4 3 2 1
leisure activities with others
22. I have trouble doing all of the family 5 4 3 2 1
activities (e.g., Host family) that I want to
do
23. I have trouble doing all of my usual 5 4 3 2 1
work, including work I do from home
24. I have trouble doing all the activities 5 4 3 2 1
with friends that I want to
Pain interference much
In the past 7 days
25. How much did pain (physical only) 1 2 3 4 5
interfere with your day to day activities?
interfere with work around the home?
interfere with your ability to participate in
social activities?
interfere with daily household chores?
Domain Raw T -score Interpretation

score Doing worse or better than average American
Physical functioning**
Anxiety*
Depression*
Fatigue*
Sleep disturbance*
Ability to participate in
social roles & activities**
Pain interference*
*T-scores more than 1 SD above the mean (M =50) represent worse functioning (of clinical concern)
**T-scores more than 1 SD below the mean (M = 50) represent worse functioning (of clinical concern)
*PROMIS-28 is a redacted version of PROMIS29. Redaction adds raw score values into domain cells, and adds a scoring
table. It omits item 29 Pain intensity. The last change does not affect comparability of PROMIS 28 T-scores w/ population norms
for the Pain domain; item #29 was not included in original PROMIS29 profile calculations.
PROMIS-28: Converting Raw Scores to T-scores
PROMIS-28 redacted for Peace Corps (PROMIS-28 ) improves ease of scoring. Although it omits item 29, pain
intensity, this does not affect comparability of PROMIS-28 results.
PROMIS-28 retains all norming comparability as the original PROMIS 29. PROMIS-28 is normed with the US
general population assesses health-related quality of life across seven (7) areas/domains of functioning, and
correlates well with other quality of life measures. T -scores in each domain of PROMIS-28 show how well a person
is functioning compared to the US general population in that domain. Taken together, PROMIS-28 results provide a
profile of wellbeing.
T-scores: For all domains of functioning on PROMIS-28, the T-score norm or Mean (M) = 50. The Standard
Deviation (SD) is in units of 10 so that one SD = 10, two SDs = 20, etc. T-scores inform us about whether someones
ability/functioning is within a normal range. In other words, normal is quantified; a T-score of 50 or within 1 SD of
50, the Mean, is normal (i.e., WNL: within normal limits)
Higher T-scores are not necessarily better! Because one SD = 10, a T-score of 40 is therefore one SD below the
Mean. Similarly, a T-score of 60 is one SD above the Mean. Deviations from the norm can mean either better or
worse functioning depending on the domain in question (see, Step 3, below).
For most PROMIS- 28 domains higher T-scores = worse functioning. This makes sense when you consider the
domains (e.g., more anxiety, or more depression is not good). In contrast, for two (2) domains (i.e., ability to
participate in social roles, and physical functioning), a lower T-score = worse functioning. This makes sense too:
less social ability or less physical functioning diminish well-being.
Step 1: Calculate raw scores (range 420)

The raw score is the simple sum of the numerical values indicated in each cell, which are a persons responses
(e.g., not at all, a little bit, ) to items in a domain (e.g., My sleep was refreshing ).
Step 2: Convert raw scores to T-scores

Look up the T-score by using the T-score Conversion Tables (next page).
Step 3: Interpret the T-scores compared to US average,50, and the SD = 10

T-scores 10 points or more higher than 50 represent substantially worse functioning in:
o Anxiety
o Depression
o Fatigue
o Sleep disturbances
o Pain
T-scores 10 points or more lower than 50 represent substantially worse functioning in:
o ability to participate in social roles and activities
o physical functioning
Domain Raw score Interpretation

T-score Doing worse or better than average American?
Physical functioning**
Anxiety*
Depression*
Fatigue*
Sleep disturbance*
Ability to participate in
social roles & activities**
Pain interference*
*Domains in which T-scores more than 1 SD above 50 = worse functioning compared to US norms
** Domains in which T-scores more than 1 SD below 50 = worse functioning compared to US norms
Revised 3/20/2015 by PMS Page 1 of 2

PROMIS-28: Converting Raw Scores to T-scores
PROMIS 28 Raw Scores Conversion Tables

Physical Anxiety Depression Fatigue Sleep Participation in Pain
functioning disturbance social roles interference
Raw T-score SE* T-score SE* T-score SE* T- SE* T-score SE* T-score SE* T-score SE*
Scores score
4 22.9 3.9 40.3 6.1 41.0 6.2 33.7 4.9 32.0 5.2 28.0 4.2 41.6 6.1
5 26.9 2.7 48.0 3.6 49.0 3.2 39.7 3.1 37.5 4.0 33.6 2.5 49.6 2.5
6 28.1 2.4 51.2 3.1 51.8 2.7 43.1 2.7 41.1 3.7 35.7 2.2 52.0 2.0
7 30.7 2.2 53.7 2.8 53.9 2.4 46.0 2.6 43.8 3.5 37.3 2.1 53.9 1.9
8 32.1 2.2 55.8 2.7 55.7 2.3 48.6 2.5 46.2 3.5 38.8 2.1 55.6 1.9
9 33.3 2.1 57.7 2.6 57.3 2.3 51.0 2.5 48.4 3.4 40.3 2.1 57.1 1.9
10 34.4 2.1 59.5 2.6 58.9 2.3 53.1 2.4 50.5 3.4 41.7 2.1 58.5 1.8
11 35.6 2.1 61.4 2.6 60.5 2.3 55.1 2.4 52.4 3.4 43.2 2.1 59.9 1.8
12 36.7 2.1 63.4 2.6 62.2 2.3 57.0 2.3 54.3 3.4 44.8 2.1 61.2 1.8
13 37.9 2.2 65.3 2.7 63.9 2.3 58.8 2.3 56.1 3.4 46.4 2.1 62.5 1.8
14 39.1 2.2 67.3 2.7 65.7 2.3 60.7 2.3 57.9 3.3 48.1 2.1 63.8 1.8
15 40.4 2.2 69.3 2.7 67.5 2.3 62.7 2.4 59.8 3.3 49.8 2.2 65.2 1.8
16 41.8 2.3 71.2 2.7 69.4 2.3 64.6 2.4 61.7 3.3 51.6 2.2 66.6 1.8
17 43.4 2.4 73.3 2.7 71.2 2.4 66.7 2.4 63.8 3.4 53.5 2.2 68.0 1.8
18 45.3 2.6 75.4 2.7 73.3 2.4 69.0 2.5 66.0 3.4 55.6 2.3 69.7 1.9
19 48.0 3.1 77.9 2.9 75.7 2.6 71.6 2.7 68.8 3.7 58.1 2.7 71.6 2.1
20 56.9 6.7 81.6 3.7 79.4 3.6 75.8 3.9 73.3 4.6 64.1 5.1 75.6 3.7
T-scores were developed to facilitate interpretation of tests results by enabling a comparison of a persons scores
against norms for a relevant population. A T-score is a standardized score that is calculated from the total
distribution of scores within a relevant community (norming) sample. For PROMIS 28, this was a representative
sample of the US adult population.
T-scores are obtained from raw scores. T-scores have a mean of 50 and a standard deviation (SD) of 10. T-scores
within one standard deviation of the mean of 50 (i.e., a T-score of 55) on any domain is regarded as being within
the normal range (WNL) for that domain, and therefore not a clinical concern.
A T-score that differs more than one standard deviation, either higher or lower depending on the domain
(explained above), shows elevated symptom or distress/problem. A one SD difference indicates sub-clinical
problems.
PROMIS 28 are NOT diagnostic. Identification of sub-clinical problems in any domain warrants follow-up and re-
assessment; this does not necessarily indicate a need for referral for psychiatric evaluation or treatment, but
indicates the need to explore the persons view of the problem, attempts resolution, and coping strategies.
When to make a mental health referral to OHS/COU:

A T-score that differs much more than one standard deviation, or at least two SDs, either higher or lower
depending on the domain (explained above) in any domain may be viewed as a good indicator of the need for
referral to a licensed mental health professional.
When an individuals PROMIS 28 profile shows multiple domains of substantially worse than average
functioning (i.e., T-scores are more than one SD from the norm).
Revised 3/20/2015 by PMS Page 2 of 2

Adjustment Disorders DSM-5 Diagnostic Criteria
Diagnostic Criteria (DSM-5: American Psychiatric Association, 2013)

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring
within 3 months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into
account the external context and the cultural factors that might influence symptom severity and
presentation.
2. Significant impairment of social, occupational, or other important areas of functioning.
C. The stress-related disturbance does not meet the criteria for another mental disorder [emphasis added] and
is not merely an exacerbation of a preexisting mental disorder.
D. The symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an
additional 6 months.
Diagnostic Specifications:
309.0 (F43.21) With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
309.24 (F43.22) With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
309.28 (F43.23) With mixed anxiety and depressed mood: A combination of depressi on and anxiety is
predominant.
309.3 (F43.24) With disturbance of conduct: Disturbance of conduct is predominant.
309.4 (F43.25) With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression,
anxiety) and a disturbance of conduct are predominant.
309.9 (F43.20) Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of
adjustment disorder.
Development and course (DSM-5: American Psychiatric Association, 2013)

By definition, the disturbance in adjustment disorders begins within 3 months of onset of a stressor and lasts no
longer than 6 months after the stressor or its consequences have ceased. If the stressor is an acute event (e.g.,
being fired from a job), the onset of the disturbance i s usually immediate (i.e., within a few days) and the
duration is relatively brief (i.e., no more than a few months). If the stressor or its consequences persist, the
adjustment disorder may also continue to be present and become the persistent form.
Further information: Consider the bell curve: the normal distribution of Volunteer reactions adjusting to Peace
Corps in your country. Ask: Where do the reactions fall on the curve? This helps you consider if reactions are out
of proportion to the severity or intensity of the stressor, taking into account the external context per DSM-5.
TG 510-Attachment D July 2015

Peace Corps
ALCOHOL MISUSE AND ABUSE
1. PURPOSE
To provide Peace Corps staff with a basic understanding and appropriate

management of alcohol abuse, including the use of screening instruments
designed to aid the PCMO in recognizing and evaluating suspected or apparent
alcohol misuse and abuse through an objective approach.
To guide the PCMO in assessing and implementing effective clinical management
of alcohol abuse and provide resources for additional information on the treatment
of acute and chronic alcohol use.
2. BACKGROUND
2.1 Definitions
Per DSM-5, Alcohol Use Disorder (AUD) is a problematic pattern of alcohol use
leading to clinically significant impairment or distress, as manifested by 2-3
(mild), 4-5 (moderate) to 6 or more (severe) of the following symptoms within a
12-month period:
Alcohol is taken in larger amounts or for longer periods than was intended
There is a persistent desire or unsuccessful efforts to control alcohol use
A great deal of time is spent in activities needed to obtain, use or recover
from alcohol
Craving, a strong desire to use alcohol
Recurrent use resulting in a failure to fulfill major role obligations at
work, school or home
Continued use despite having recurrent interpersonal or social problems
caused by alcohol
Important social, occupational or recreational activities are given up or
reduced
Recurrent use in situations where it is physically dangerous
Use is continued despite knowledge of a persistent / recurrent physical or
psychological problems, caused by or exacerbated by alcohol
Tolerance (need for markedly increased amounts or markedly decreased
effects
Withdrawal
Alcoholism is not a clinical diagnosis. It is sometimes used to describe any single

type (mild, moderate or severe) of Alcohol Use Disorder (AUD). Persons who are
in remission from alcohol use may use recovering alcoholic; to describe their
abstinence. Diagnostically, the term Alcohol Use Disorder in remission or in
early remission is used. If none of the above 11 criteria is met for 3 months (but
not yet 12) the AUD is considered to be in early remission.
Office of Health Services December 2015 Page 1

Alcohol Misuse and Abuse
TG 520
Intoxication: A spectrum of alteration of behavior and/or conscious state caused

by alcohol or drug ingestion.
Withdrawal: A psychological and/or physical syndrome caused by the abrupt

reduction in dose, or cessation of, a substance whose use has been heavy and
prolonged. Approximately 50% of middle-class, highly functioning individuals
with AUD have ever experienced a full alcohol withdrawal syndrome (though the
rate is approximately 80% for homeless or hospitalized for AUD.) Fewer than
10% of individuals in withdrawal ever demonstrate alcohol withdrawal delirium
or withdrawal seizures.
Detoxification: The process of safely removing a drug from the body.
Blackout: Periods of intoxication for which there is partial or complete

anterograde amnesia, during which the person appears awake and alert.
Occasionally, can last up to days with the intoxicated person performing complex
tasks. (Kaplan and Sadock, 1990)
2.2 Current Information on the risk of developing Alcohol Use Disorder

(DSM-5)
Environmental: A cultural attitude toward drinking and intoxication, alcohols

availability (including price), acquired personal experiences, and stress levels can
all contribute to AUD. Additionally, heavier peer use and suboptimal ways of
dealing with stress may also contribute.
Genetic and physiological: AUD runs in families with 40-60% of the variance of
risk explained by genetic factors. AUD is 3 to 4 times more common in people
with a close relative with AUD.
Gender: Males have both higher rates of drinking and of AUDs than females.
However, due to differences in weight, body fat, and metabolism, females are
likely to develop higher blood alcohol levels per drink than are males.
Culture: An estimated 3.6% of the global population has a current (within the last
12 months) AUD. The lowest prevalence is in Africa (1.1%); moderate
prevalence (5.2%) in the Americas and Caribbean; and the highest rate (10.9%) in
the Eastern Europe region. Due to genetic variations in alcohol-metabolizing
enzymes, alcohol use in as many as 40% of Japanese, Korean, Chinese and related
groups results in physical reactions so unpleasant that alcohol consumption of any
kind and the prevalence of AUD are significantly reduced in these populations.
An estimated 3.89% of all global deaths and 4.6% of global disability-adjusted-
life-years are attributable to alcohol.
Prevalence: The 12-momth prevalence of AUD is 8.5% among adults 18 and

older in the United States. Rates are greater among US adult men (12.4%) than

TG 520
women (4.9%). However, 22.5% of US adults age 26 or older (and 37.7% of

young adults) report binge drinking (5 or more drinks on one occasion) within the
past 30 days; 6.2% of US adults (and 10.8% of young adults) report heavy
drinking (5 or more drinks on each of five or more days.) (US National Survey on
Drug Use and Health, 2014)
Development and Course: Meeting diagnostic criteria for AUD peaks in the late
teens to early 20s. The large majority of those who develop more serious alcohol-
related disorders do so by their late 30s.
There are numerous myths about alcohol use. Several of the more common ones
include:
Myth I can drink and still be in control.

Fact Drinking impairs your judgment, which increases the likelihood that you will do
something you regret such as having unprotected sex, being involved in date rape,
damaging property or being victimized by others. .
Myth Alcohol improves my sexual performance
Fact Although you may think so, psychologically alcohol reduces your performance.
Myth Its okay for women to drink to keep up with male friends.
Fact Women process alcohol differently. No matter how much a male drinks, if a female
drinks the same amount, she will be more intoxicated and more impaired.
Myth Id be better off if I learn to hold my liquor.

Fact If you have to drink increasingly larger amounts of alcohol to get a buzz, you are
developing tolerance. This increases your vulnerability to many serious problems,
including alcoholism.
Myth I have to drink to fit in.

Fact Your peers dont drink as much as you think they do. A recent survey of more than
44,000 college students shows that most students drink little or no alcohol on a
weekly basis.
Myth I can sober up quickly if I have to.

Fact It takes about 3 hours to eliminate the alcohol content of two drinks, depending on
your weight. Nothing can speed up this processincluding coffee and cold showers
. (From: Top 10 Myths About Alcohol Use, University of San Diego)

TG 520
3. PREVENTION
Peace Corps staff should actively prevent alcohol abuse among volunteers by:
Developing a culture of responsible alcohol use through development of a country

alcohol policy, prevention training, and prompt management of PCVs with binge
drinking problems through PCMO/CD/staff collaboration.
Administering the Alcohol Use Disorders Identification Test (AUDIT) to each
trainee individually during PST, educating each trainee about the meaning of
his/her AUDIT score, and offering to assist in cutting back/stopping drinking.
Use of the AUDIT is the responsibility of the PCMO.
Providing information on alcohol abuse through group presentations/discussions

PST, IST, MST, COS as well as in individual consultations.
Becoming familiar with and educating on other substances of abuse (e.g., coca
leaf, locally fermented beverages, marijuana, and other illicit drugs) in the country
of practice as well as their effects alone or in combination with alcohol
4. MANAGING ALCOHOL USE DISORDER
This is a medical diagnosis which generally required consultation with OHS. PCMOs in
collaboration with the CD, SSM, and DPT should assess alcohol-related problems in
terms of the Volunteers safety, conduct and ability to complete role expectation at work
and home. Consult OHS for assistance whenever necessary.
PCMOs must know what steps to take when confronted with Volunteer alcohol abuse.
Some questions to be answered include:
Is the information about suspected abuse accurate and consistent?

How serious is the problem?
Should OHS be consulted?
Can the situation be managed in-country?
Is alcohol withdrawal likely?
What local resources can be utilized?
5. THE EVALUATION INTERVIEW AND USE OF THE SCREENING

QUESTIONNAIRES
5.1 Alcohol and Substance Abuse Evaluation Interview
All PCMO contacts with volunteers suspected of alcohol or drug abuse must be made in
person. Contact may take place through a site visit, or the volunteer may be brought to
the health unit.

TG 520
The Substance Abuse Evaluation Interview (outlined below) can be used to guide the
history taking, examination, assessment, and development of a management plan.
The PCMO should remain friendly and helpful throughout the evaluation interview
and, at the same time, firmly remind the Volunteer that strong evidence of a problem
exists.
ALCOHOL AND SUBSTANCE ABUSE EVALUATION INTERVIEW

SUBJECTIVE
Describe the report(s) you have received to the volunteer
Allow the Volunteer to give his or her version of the events
Ask/observe his or her reaction and concerns
Current use of alcohol or drugs and level of functioning
Did you use alcohol prior to Peace Corps?
What do you drink?
How much do you drink?
What medications are you taking?
Do you use other drugs?
Specific use in the last week?
Family history (grandparents, parents, siblings). Ask if there were instances of:
Alcohol abuse or substance abuse
Psychiatric or mental illness
Anti-social behavior (jail or arrest)
Legal problems (DUI)
OBJECTIVE
Physical Examination
General condition, abrasions, bruises?
Spider veins?
Enlarged liver?
Abdominal tenderness? (ulcer, gastritis, pancreatitis)
Unsteady gait? Tremor?
Needle track marks?
Rectal exam for stool guaiac? (ulcer, gastritis)
Mental Status
Complete a mental status exam (TG 510)
Laboratory Tests
CBC (with MCV)
Liver enzymes (increased transaminases may indicate alcoholic hepatitis, esp. GGT)
Blood alcohol
Blood and/or urine toxicology screen
ASSESSMENT
Utilize the AUDIT screening questionnaire

TG 520
5.2 The Alcohol Use Disorders Identification Test (AUDIT)
The AUDIT can detect alcohol problems experienced in the last year. It is a 5-minute
screening instrument, tested internationally in primary care settings, and has high
levels of validity and reliability. (Attachment A).
Scoring the AUDIT
A minimum score (for nondrinkers) is 0 and the maximum possible score is 40.
Scores of 8 or more for men (up to age 60) or 4 or more for women, adolescents, and
men over the age of 60 are considered positive screens. For patients who have scores
near the cut-points, clinicians may wish to examine individual responses to questions
and clarify them during the clinical examination.
6. MANAGEMENT OF ALCOHOL MISUSE AT POST

For those Volunteers who consume more than three drinks per session The All-Volunteer
Survey (AVS, 2014) lists the following factors as reasons for alcohol consumption:
Personal enjoyment
The drinking habits of fellow Volunteers
Stress reduction
Continued my US drinking habits in country
Those results vary by country in rank, but most countries AVS scores responses to this question
have each of these responses in the four among the five that are most often cited. Attempts at
decreasing excessive drinking at the Post level may logically begin with interventions to address
one or more of the above factors.
The management of alcohol misuse at post is not solely the PCMOs responsibility.
Collaboration with the Country Director and other members of the staff as well as Volunteers in
leadership positions (VAC; PCVLs; PSN) is critical. Post is encouraged to consult a 2015
publication of the National Institute of Alcoholism and Alcohol Abuse (NIAAA) titled College
AIM. Interventions at both individual and environmental levels are all evidence supported and
are scored on effectiveness and cost. Though prepared for university settings (where most of the
cited research is centered), the applicability to Peace Corps is clear.
Beginning with interventions focused on the four factors Volunteers report as causal in their
drinking habits would likely prove to be most beneficial.
College-age PCVs may come from an environment where binge-drinking (>4-5 drinks in one
setting) is highly prevalent, causing health and safety risks. The safety risks in Peace Corps are
often much more severe than those in a university setting.
Some research has shown that an important step in stopping alcohol abuse is to change the
culture which is the drinking habits of fellow Volunteers. Recommendations for developing a
culture of responsible alcohol use may include:
developing a country alcohol policy
not serving alcohol at Peace Corps-sponsored events
preventive training
prompt management of PCVs with binge drinking problems through PCMO/CD/staff
collaboration.
TG 520
MANAGEMENT AGREEMENTS
When counseling a volunteer who has a problem with alcohol, it is often useful to have the
Volunteer agree to certain commitments. Written agreements are preferable. The objective is to
have the volunteer set the terms of the agreement rather than have terms imposed. The terms of
the agreement should be voluntary, realistic, and specific to the areas of concern for the
volunteer. Generic agreements prepared in advance are not generally appropriate.
SAMPLE MANAGEMENT AGREEMENT

I agree to carry out the following: Have the volunteer propose the terms of the agreement
1) To report for a follow-up appointment on (specify date and time)

2) Not to (drink alcohol, get drunk, have more than two drinks a day) in that time
3) Not to take any other form of drug in that time (unless discussed with PCMO)
4) To contact you immediately if I am unable to comply with this agreement
5) Accept full responsibility to call you in (specify time; weekly at a specific time) to give
you a status report.
In agreeing to these terms, I also understand that failure to comply with them may result in
(consultation with OMS, other action)
Signature of Volunteer Signature of PCMO
Signature of CD
7. ALCOHOL WITHDRAWAL
Individuals who are physically dependent on alcohol will experience withdrawal symptoms if
they abruptly stop using the alcohol or significantly reduce its intake.
Alcohol dependent Volunteers may first present in withdrawal or may stop using the
alcohol during assessment and then go into withdrawal.
Volunteers requiring supervision for alcohol-related problems must be supervised by the
PCMO or by another Peace Corps staff member and may not be supervised by another
Volunteer.
When caring for a Volunteer who is or has been abusing alcohol, the following questions
must be answered:
Should OMS be contacted?

Are complications from withdrawal likely?
Can the Volunteer safely withdraw in-country?
Should pharmacologic detoxification be used?
Should supervised maintenance alcohol consumption be used to delay withdrawal?

TG 520
7.1 Complications of Alcohol Withdrawal
Alcohol withdrawal can be unpleasant but uncomplicated, or it can be complicated by

seizures or delirium tremors. In uncomplicated withdrawal, symptoms peak between 24-48
hours after the last drink and subside in five to seven days, even without treatment.
Symptoms of Mild Alcohol Withdrawal:
Tremor of the hands, tongue and eyelids

Nausea and vomiting
Malaise and weakness
Rapid pulse, sweating, mild elevation of blood pressure
Anxiety, depressed mood, or irritability
Orthostatic hypotension
Headache and dry mouth
Insomnia
Symptoms of Severe Alcohol Withdrawal:
Alcohol withdrawal seizures are grand-mal seizures which usually start within 48 hours of
the last alcohol use.
Delirium Tremens (DTs), a potentially life-threatening condition, can occur within a week of
the reduction or cessation of heavy and prolonged (usually years) alcohol intake. It is
characterized by:
Agitation, tachycardia, hypertension, sweating, and insomnia

Transient hallucinations (visual, auditory, or tactile), or other perceptual distortions that
provoke terror and agitation
Fluctuating confusion and disorientation
Death can result from cardiac arrhythmias (usually associated with hyperkalemia,
hyperpyrexia, and poor hydration)
It is not always possible to predict who will develop seizures or DTs during alcohol
withdrawal. However, they are more likely if:
Drinking has been heavy or prolonged
A past history of seizures or DTs exist
Other medical problems or complications are present
7.2 Managing Alcohol Withdrawal
Management of mild withdrawal symptoms involves supervising and reassuring the patient,
maintaining hydration, and possibly using low to moderate doses of pharmacologic
detoxification (see chart below).
Management of severe withdrawal symptoms involves continuous supervision of the patient,

obtaining expert advice from OMS and/or the RMO, and pharmacologic detoxification in doses
adequate to control symptoms. Persons at risk for severe withdrawal as defined in section 7.1

TG 520
should be closely monitored and pharmacologic detoxification given if any signs of withdrawal
are seen. Medications may be started before symptoms are seen if the patient has experienced
withdrawal in the past.
Pharmacologic Detoxification
Benzodiazepines are used in the management of alcohol withdrawal to:
Control the symptoms of withdrawal
Reduce the likelihood of seizures
Reduce the chance of other medical complications
Relieve physical and psychological discomfort
Benzodiazepines are NEVER used if alcohol has been consumed in the past 24
hours.
Drug Regimens for Pharmacologic Detoxification from Alcohol
Chlordiazepoxide (Librium) Oral: Initial dose: 50-100 mg; dose may be
repeated as necessary to a maximum of 300
mg per 24 hours. Once agitation is under
or control, maintain therapy at lowest
effective dose.
Diazepam (Valium) Oral: 10 mg 3 to 4 times during first 24

hours, then decrease to 5 mg 3 to 4 times
daily as needed
or
Lorazepam (Ativan) Oral (fixed-dose regimen): 2 mg every 6

hours for 4 doses, then 1 mg every 6 hours
for 8 additional doses
Oral (symptom-triggered regimen): 2 to 4

mg every 1 hour as needed; dose
determined by a validated severity
assessment scale
Start with lower doses if symptoms are mild, increase dose if symptoms do not
respond to a lower dose or if symptoms are severe.
Supervised Maintenance Alcohol Consumption
If benzodiazepines are not available or are refused, withdrawal may be postponed or prevented
by allowing the Volunteer to continue supervised alcohol consumption while being medevaced.
Pharmacologic detoxification is preferred and is easier to regulate than supervised alcohol
consumption. The dose of alcohol should be gradually reduced over 5 days.

TG 520
Bibliography
Barbor, T. E., La Fuente, J. R., Saunders, J., & Grant, M. (1992). AUDITThe alcohol use
disorders identification test: guidelines for use in primary health care. Geneva: World Health
Organization.
College AIM NIAAA's Alcohol Intervention Matrix. (2015). Retrieved from

http://www.collegedrinkingprevention.gov/CollegeAIM/Default.aspx
DSM-5 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders. Arlington: American Psychiatric Publishing.
Kaplan, H.I. and Sadock, B.J. (1990). Pocket Handbook of Clinical Psychiatry. Lippincott
Williams & Wilkins
National Survey on Drug Use and Health. (2015). SAMHSA/HHS Publication, (15-4927)
US Department of Health and Human Services. (2005). Helping patients who drink too much: a
clinicians guide. National Institutes of Health. National Institute on Alcohol Abuse and
Alcoholism. NIH Publication, (07-3769).

Alcohol Abuse
TG 520 Attachment A
ATTACHMENT A
THE CAGE QUESTIONNAIRE
C Have you ever felt the need to Cut down on your drinking?
A Have you ever felt Annoyed by someones criticizing your drinking?
G Have you ever felt bad or Guilty about your drinking?
E Have you ever needed a drink first thing in the morning to steady your nerves and
get rid of a hangover? (Eye-opener)
Office of Medical Services December 2005 Page 1

Alcohol Abuse
TG 520 Attachment B
ATTACHMENT B
THE AUDIT QUESTIONNAIRE
Place an X in one box that best describes your answer to each question or circle the
number that comes closest to the patients answer.
Questions 0 1 2 3 4
1. How often do you have a drink Never Monthly 2 to 4 2 to 3 4 or more
containing alcohol? or less times a times a week times a week
month
2. How many drinks containing alcohol 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
do you have on a typical day when you
are drinking?
3. How often do you have five or more Never Less Monthly Weekly Daily or
drinks on one occasion? than almost daily
monthly
4. How often during the last year have Never Less Monthly Weekly Daily or
you found that you were not able to than almost daily
stop drinking once you had started? monthly
you failed to do what was normally than almost daily
expected of you because of drinking? monthly
you needed a first drink in the morning than almost daily
to get yourself going after a heavy monthly
drinking session?
you had a feeling of guilt or remorse than almost daily
after drinking? monthly
you been unable to remember what than almost daily
happened the night before because of monthly
your drinking?
9. Have you or someone else been No Yes, but Yes, during

injured because of your drinking? not in the the last year
last year
10. Has a relative, friend, doctor, or No Yes, but Yes, during
other health care worker been not in the the last year
concerned about your drinking or last year
suggested you cut down?
Total
Office of Medical Services December 2005 Page 1

Peace Corps
PSYCHIATRIC EMERGENCIES
1. PURPOSE
The purpose of this guideline is to provide the PCMO with information on the assessment, diagnosis
and management of psychiatric problems, including severe depression, suicide risk, acute anxiety,
and acute psychosis.
2. PREVENTION
PST and IST are opportunities to assist Volunteers with emotional adjustment, including the phases
of adjustment to Peace Corps service and critical periods in the life of a Peace Corps Volunteer.
Self awareness, acceptance of attitudes and values, and the development of effective coping
strategies and stress management techniques can be taught. Refer to the Pre-Service Health
Training on mental health.
PCMOs must be prepared to deal with psychiatric emergencies. Such preparation includes:
Identification of local health care providers and facilities to assist with psychiatric emergencies.
24-hour access to medication required for the treatment of psychiatric emergencies. These
medications must be stocked in the Peace Corps Health Unit and in the Go Bag.
Arrangements with Peace Corps staff, security guards, and other medical personnel for
assistance in managing a violent or agitated patient.
3. MANAGEMENT OF PSYCHIATRIC EMERGENCIES
Not all persons presenting with what appears to be a mental problem have a psychiatric illness.
Some medical conditions can present with signs similar to those of psychiatric diagnoses
Alterations in mental status can be due to infection (e.g., malaria), disease (e.g., vitamin
deficiency), drugs (e.g., amphetamines), adverse reactions to medication, head injury or other
intracranial lesion, or a psychiatric illness.
A complete history (medical and psychiatric) and physical exam (including a mental status exam)
and appropriate laboratory studies are necessary to correctly diagnose the cause of alteration in
mood, thought, or behavior.
Always provide a safe environment for a Volunteer experiencing an acute psychiatric disorder.
Provide accompaniment or supervision in all cases, and medicate when appropriate (as
described below.) Do not permit acutely suicidal or psychotic individuals to be alone, even if
they desire to work it out by themselves.
Office of Health Services June 2014 Page 1

Psychiatric Emergencies
TG 530
MANAGEMENT OF PSYCHIATRIC EMERGENCIES
SUBJECTIVE
Statement of the presenting problem: Why are you here?
Current and past use of alcohol, drugs, medications
Past psychiatric history including: prior episodes, diagnoses, hospitalizations, medication
use and response
Past social history including: marriage, divorce, deaths, separation, trauma, abuse
Family history of psychiatric problems
Past and current medical problems
Current coping strategies
OBJECTIVE
Examination
Perform a mental status examination (ATTACHMENT A)
Perform a physical examination (as much as possible) with special regard to:
- vital signs and temperature
- evidence of head injury
- evidence of drug use or intoxication
If unable to complete the examination, document the reason(s)
Laboratory screening tests

If an underlying medical illness is suspected, some of the following tests may be indicated:
A rapid blood glucose determination and pulse oximetry should be obtained in all
combative patients
CBC with differential white blood count
Urinalysis
Electrolytes
Malarial smear
Blood glucose
Liver and renal function tests
Pregnancy Test
Thyroid function
Toxicology screen
ASSESSMENT AND PLAN

The following psychiatric disorders should be identified and initial management performed as
described in this guideline. All psychiatric emergencies will require assistance from local
consultants (if available) and from the RMO or OMS and COU.
PSYCHOSIS (an inability to recognize reality, and communicate and relate to others)
DEPRESSION with or without SUICIDE RISK
ACUTE ANXIETY

TG 530
4. ACUTE PSYCHOSIS
A patient with acute psychosis has an impaired sense of reality and may talk and act in a bizarre
fashion. He or she may be confused and agitated, but may remain oriented. Other features of
psychosis include:
Thought disorganization: sudden and incomprehensible changes of subject and obvious flaws
in reasoning
Delusions: false beliefs (e.g., I am the messiah)
Hallucinations: the perception (visual, auditory) of objects or events which do not exist (e.g.,
hearing voices, seeing things which are not present)
Mood disturbance: patient may appear unduly depressed or excited.
4.1 Classification of Psychosis
Psychosis is classified as having either a physical (organic) or functional cause.
4.1.1 Physical (organic) psychosis (Psychosis secondary to a medical condition)

requires urgent medical intervention. Contact OMS/RMO/COU.
Neurologic problems: CNS infections; neoplasms, vascular events, cognitive

disorders, seizures
Endocrine dysfunctions: thyroid, parathyroid, or adrenal abnormalities
Metabolic problems; hypoxia, hypercarbia, hypoglycemia, fluid or electrolyte
abnormalities, and aberrant copper clearance
Hepatic and renal disorders
Autoimmune disorders: systemic lupus erythematosus
4.1.2 Functional psychosis requires immediate psychiatric evaluation. Contact

OMS/RMO/COU.
There is no underlying medical condition. Diagnoses include schizophrenia,

schizophreniform disorder, brief reactive psychosis, induced psychotic disorder,
delusional disorder and affective disorders with psychotic features.
Auditory hallucinations are characteristic of functional psychosis.
The use of anti-psychotic medication may be required.
4.2 Management of Functional Psychosis
Management is focused on bringing the Volunteers symptoms under sufficient control to

allow safe medical evacuation to the United States for definitive diagnosis and treatment.
Refer to the package insert or Up-to-Date for a full discussion of the side effects of individual
drugs.

TG 530
The PCMO should inquire about previous treatment with antipsychotic medication. If such
treatment has been given and was successful, that particular antipsychotic medication (if
available) is the drug of choice for that patient.
Antipsychotic use
Haloperidol (Haldol):
In the United States, haloperidol is the drug of choice for the rapid control of acute psychosis.
Oral dosing is appropriate unless very rapid onset is necessary.
Recommended dose of haloperidol (oral)

Initially 2 to 5 mg orally two to three times a day*
Adjust dose according to response. Most patients will respond to a total of 10-15 mg per day.
Give diphenhydramine (Benadryl) 50mg every 6-8 hours to prevent acute side effects and to
provide additional sedation.
Agitated patients should receive a benzodiazepine in addition to haloperidol as long as they are
not intoxicated (see below.)
* Note: Dosage will vary depending on the severity of the symptoms and the individuals
response to the medication. Significantly higher or lower doses may be necessary.
Recommended dose of haloperidol (intramuscular)

Initially 2 to 5 mg* intramuscularly
May repeat hourly or at 2-8 hour intervals until able to administer orally. Begin oral course
with total daily dose equivalent to amount given IM in first 24 hours (give as divided doses two
or three times a day.)
Give diphenhydramine (Benadryl) 50mg every 6-8 hours to prevent acute side effects and to
provide additional sedation.
Agitated patients should receive a benzodiazepine in addition to haloperidol as long as they are
not intoxicated (see below.)
* Note: Dosage will vary depending on the severity of the symptoms and the individuals
response to the medication. Significantly higher or lower doses may be necessary.
Risperidone (Risperdal)
Risperidone is a second generation psychotropic agent with fewer extrapyramydal side effects
in lower doses.
Recommended dose of Risperidone (oral)

Initially 1-2 mg every 30 minutes to 2 hours, to a maximum of 4 mg per day

TG 530
Side-effects of anti-psychotics
The side effects of anti-psychotic medications include drowsiness, sedation, hypotension,

extrapyramidal symptoms (e.g., tremors, rigidity, and akathisia), photosensitivity and
hepatotoxicity. Such symptoms are more commonly seen with haloperidol than with
risperidone.
Extrapyramidal side effects can be managed with diphenhydramine (Benadryl) 50 mg IM or

PO. It is as effective as benzotropine (Cogentin) 1mg or trihexphenidyl (Artane) 1mg for acute
extrapyramidal side effects and has the additional benefit of providing sedation.
Benzodiazepine use
Antipsychotic medications at standard doses do not provide adequate sedation for many
patients. Agitation or anxiety which persists despite use of an antipsychotic medication requires
the addition of a benzodiazepine. In addition, sedation with a benzodiazepine is helpful during
travel to help prevent agitation or a psychotic relapse.
**Benzodiazepines should NEVER be used with intoxicated patients
Lorazepam (Ativan) 2-4 mg, PO offers rapid onset of action and a long half-life (14 hours) to
prevent rapid fluctuation in level of sedation. If administering IM, a lower initial dose (0.5 mg) is
indicated.
If Lorazepam is unavailable, alternative benzodiazepines can be used. Check medication

information for appropriate dose.

TG 530
5. DEPRESSION
5.1 Background
The following criteria to classify depression appear in the Diagnostic and Statistical Manual
(DSM-V) published by the American Psychiatric Association.
DIAGNOSTIC CRITERIA FOR A MAJOR DEPRESSIVE EPISODE
At least five of the following symptoms have been present in the same two-week period and
represent a change from previous functioning. At least one of the symptoms must be the first
or second in the list.
(1) Depressed mood most of the day, nearly every day, as indicated either by subjective
account or observation by others.
(2) Markedly diminished interest or pleasure in all, or almost all, activities of the day, nearly
every day (as indicated by subjective account or observation of others.)
(3) Significant weight loss (when not dieting) or weight gain (a change of more than 5% of
body weight in a month) or decrease or increase in appetite nearly every day.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day (observed by others.)
(6) Fatigue or loss of energy nearly every day.
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self reproach or guilt about being sick).
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day.
(9) Recurrent thoughts about death, recurrent suicidal ideation without a specific plan, or
suicide attempts or a specific plan for committing suicide.
Also, the symptoms must cause clinically significant distress or impairment in s ocial,
occupational, or other important areas of functioning, and must not be caused by the effects of
a substance or by a general medical condition. Note that bereavement (grief) may meet these
criteria, especially within the first 2 months.
5.2 Suicide Risk

A depressed patient may be contemplating suicide. It is important to explore the possibility of
suicide in any depressed patient so that preventive action can be taken, if necessary. Factors
which increase the risk of suicide include:
Previous attempt or threat

Male, 15-25 years or >55 years
Women, 55-65 years
Socially isolated, living alone
Marital status of separated, widowed or divorced
Prominent feelings of hopelessness.
Heavy alcohol intake
Poor physical health
Recent separation from a loved one; bereavement
Presence of Borderline Personality Disorder
Recent initiation of and SSRI in patients under the age of 25

TG 530
Management of a suicidal patient

Any Volunteer expressing suicidal ideation must be managed as an EMERGENCY. The
patient must be observed either in the Health Unit or a suitable local psychiatric facility.
Observation may be either continuous or intermittent, depending on the degree of suicidality.
Contact OMS and/or RMO and COU immediately. Contact a suitable local psychiatrist, if
available.
The goal of management will be to stabilize the situation and reduce the symptoms in order to
arrange for probable medevac for to the U.S. for definitive diagnosis and treatment. The
PCMO, another medical provider, or another Peace Corps staff member may be selected to
supervise a suicidal patient (see section 7). Volunteers who require supervision may not
be supervised by another Volunteer.
5.3 Management of a depressed patient without suicidality

Re-evaluate the Volunteers condition and assess for suicide risk frequently. The level of
clinical supervision should be consistent with the severity of the depression. Daily observation
is appropriate for acutely or severely depressed patients.
See the patient frequently and if there is no improvement, discuss the patients condition with
OMS/the RMO and COU or a suitable local psychiatrist. The patient may require medevac
for further evaluation and treatment.
Antidepressant medication may be started in consultation with in-country medical experts in
case an emergency treatment is required. OMS/RMO must be consulted as soon as
practical.
The management of depression involves:
Removal of stressful situations. It may be beneficial for the Volunteer to remain at the
Health Unit (or in the capital) until clinical improvement is observed.
Advise the Volunteer to avoid alcohol.
Thorough mental health assessmentsee Technical Guideline 510 Mental Health
Assessment and Support.
Restoration of normal sleep patterns. Use a hypnotic medication if necessary (e.g.,
zolpidem (Ambien) or eszopiclone (Lunesta).
6. ACUTE ANXIETY
Background
Anxiety is the apprehension of danger and dread and is often accompanied by restlessness and
tension. Anxiety may exist as an isolated condition or may be associated with other medical or
psychiatric conditions.
Underlying causes of anxiety include:

TG 530
Medical conditions such as hypoxia, shock, and pain

Drug use and/or withdrawal
Depression
Management of acute anxiety (without underlying medical or psychiatric condition)
A short course of a minor tranquilizer may alleviate the problem. This treatment should not be
extended for more than a week, at which time the dosage should be tapered by giving the night-time
dose only for several days. If there is no improvement or there is an ongoing need for anxiolytics,
discuss the patients condition with OMS/the RMO and COU. Use of an SSRI may be indicated.
Evaluation by a psychiatrist is useful, if available. Assure that the patient is not consuming alcohol.
Short acting benzodiazepine:

Lorazepam (Ativan) 1mg orally three times daily* for no more than 1 week
OR
Alprazolam (Xanax) 0.5 - 2mg orally three times daily* for no more than 1 week
Reduce to a night-time dose only for days 8-10 (i.e., for three days after completing a course)
Long acting benzodiazepines:

Diazepam (Valium) 2.5 or 5 mg orally three times daily* for 5-7 days
Reduce to a night-time dose only for days 8-10 (i.e., for three days after completing a course)
*The lowest effective dose should be used. Dosage will vary depending on the severity of the
symptoms and the individuals response to the medication. Significantly higher or lower doses
may be necessary.
7. SUPERVISION OF PSYCHIATRIC PATIENTS
Some psychiatric patients require 24 hour supervision (a safety watch). This is especially true for
suicidal and psychotic patients who must be protected from themselves. A safety watch is a
temporary measurethe patient must improve in 2 - 3 days or alternate arrangement must be made
(e.g., admission to local facility or medevac.)
Key elements of a safety watch

The safety watch is arranged and supervised by the PCMO. The patient is assessed each day
to determine the ongoing risk. The patient is discussed daily with OMS, the RMO and/or
COU.
Watchers work in shifts (at least 3) and must remain alert, awake and never let the person out
of their sight for any reason. Arrangements to continue the safety watch even during bathroom
visits are necessary for actively suicidal or psychotic persons. A PCMO alone cannot perform
continuous shifts.
Peace Corps staff members, Embassy staff, and other medical professionals may be asked to
assist. PCMOs should never take on this responsibility without the active involvement of other

TG 530
Peace Corps staff. Volunteers must not be permitted to serve on a watch shift alone, but may
assist non-Volunteer watchers.
The location selected must be safe with all potentially harmful objects removed (e.g.,
sharps like razors, knives, glass, hand mirrors, weapons, any pills or medicines of any kind,
open windows.)
Watchers need to be:
Responsible and reliable.
Persons who are trusted by the patient (when possible.)
Therapeutic and non-judgmental when interacting with the patient.
8. MEDEVAC
In general, medical evacuation (by commercial carrier) can only be performed when the Volunteers
symptoms are sufficiently under control that travel without incident is anticipated. Remember that a
Volunteer may become claustrophobic or agitated on an airplane or in the airport (especially during
customs and immigration procedures.)
In preparing the medevac, staff should be honest with the Volunteer. It should be stressed that the
medevac is for further diagnostic procedures and treatment is in the patients best interest. The
PCMO or other staff should not deceive the patient regarding purpose or destination.
If the PCMO is not a US citizen, please ask the Country Director to contact the US ambassador in
country to assist in expediting US Immigration and Customs procedures and assure that the PCMO
and Volunteer are not in separate immigration lines at the first point of entry into the US.
The Volunteer must be accompanied by a medically trained escort capable of administering and
monitoring medications required during travel. In some cases, two escorts may be required. In
unusual circumstances, the additional escort may be another Volunteer.
The escort must:

Know and understand the Volunteers current condition and treatment.
Advise the airline that a PCMO is bringing injectable medications onboard.
Be able to monitor for adverse signs and symptoms.
Be able to administer medication as required.
Document all of the above actions in chronological notes for insertion in the Medical Record.
Hand-carry and safeguard the Volunteers Health Record. The Health Record must not be
given to anyone other than Peace Corps Health Services staff. The PCMO should prepare a
summary of history, current status, and lab results to be given to the receiving physician.
Stay with the Volunteer until the Volunteer is either admitted to a hospital, turned over to a
consultant, or turned over to OHS staff. The PCMO escort responsibilities end at this point.

TG 530
Ideally, the escort should be the same sex as the patient to facilitate supervision during bathroom
visits. If two escorts are required, one should be the same sex as the patient. A same sex
escort is essential for actively suicidal patients.
Procedure on arrival in the U.S.
If the patient and escort arrive to a non-DC airport:

During office hours, call the Office of Medical Services.
Outside office hours, contact the medical duty officer. The escort should leave full name and a
return phone number. If there is no response in 15 minutes, call again.
The escort should give a verbal report and the Health Record to the IHC covering the country
on the next business day.
If the patient and the escort arrive to a DC airport:

They will be met by a COU clinician who will conduct a brief mental status exam at the airport
and try to reach a shared decision about whether the patient will be admitted to a local hospital
or be escorted to the medevac hotel.
If hospital admission is elected (or required) the IHC, if not already at the airport, will meet the
patient at the hospital admissions area.

Management of Sexual Assault
TG 542
Peace Corps
SEXUAL ASSAULT FORENSIC EXAM AND EVIDENCE COLLECTION
BY THE PCMO
TABLE OF CONTENTS
1. Purpose
2. PCMO Responsibilities
3. PCMO Preparations For Sexual Assault Forensic Exam (SAFE)
4. Clinical Management
a. Managing the Initial Report of a Rape
b. Preparing the Volunteer for a Sexual Assault Examination by the PCMO
c. Taking the History
d. Performing the Exam
e. Documenting the Exam
5. Collecting Evidence
a. Before the PCMO Collects Forensic Evidence
b. Forensic Evidence to Collect
c. Basic Rules of Evidence Collection
d. Evidence Collection Procedure
e. Photographing Evidence
f. Summary Chronologic Note
g. Drug Facilitated Sexual Assault (DFSA)
h. Drug Testing Guidance
i. Ordering and Maintaining Sexual Assault Kits (SAK)
6. Registered Nurse PCMO Privileges for Sexual Assault
7. Attachments
Attachment A: VEC#100 Consent Form
Attachment B: Summary Chronologic Note Outline
Office of Health Services January 2015 Page 1

TG 542
1. PURPOSE
To establish procedures for Peace Corps Medical Officers (PCMOs) to perform a sexual
assault forensic exam (SAFE), if requested by the PCV victim and either (1) the perpetrator
is another Volunteer or a Peace Corps staff member or (2) the assault took place in a building
or on land used by the U.S. government or in a residence used by a Volunteer, a U.S.
government employee or other U.S. government personnel.
2. BACKGROUND
The purpose of the SAFE is to collect forensic evidence to help the Volunteer pursue legal
action after a sexual assault. The SAFE is comprised of a comprehensive history and
examination with special attention to physical injuries, emotional distress, and the collection
of evidence for future legal proceedings as prescribed jurisdictional law. Forensic evidence
is used to:
Support a victims history
Confirm recent sexual contact
Show that force or coercion was used
Possibly assist in identifying the attacker
PCMOs are not authorized to perform SAFE exams in general. In the event that a sexual
assault is perpetrated against a Volunteer who wants to pursue legal action that may result in
the case adjudicated in the United States, the PCMO may collect forensic evidence of the
Volunteer. For Volunteer on Volunteer or Staff on Volunteer Sexual Assaults, the incident
may be prosecutable under U.S. law. In order for the PCMO to offer to conduct the SAFE,
the following requirements must be met and the Volunteer must want to have a SAFE
conducted by the PCMO. The requirements are:
This incident is a rape or aggravated sexual assault;
The perpetrator is another Volunteer, a U.S. direct-hire Peace Corps staff member, a
U.S. citizen Peace Corps contractor (including a personal services contractor), or a
U.S. citizen embassy employee;
The assault took place in the Volunteers residence, or the residence of the perpetrator
or in a U.S. government building.
The Volunteer has declined to file a complaint with host country law enforcement,
but has expressed interest in reporting to law enforcement in the U.S.; and
The Volunteer has declined to have a SAFE in accordance with host country law.
Examination can occur only if the Volunteer has given consent. The clinical components and
approaches to collecting evidence through a SAFE outlined in this Technical Guideline are
based on A National Protocol for Sexual Assault Medical Forensic Examinations:
Adults/Adolescents (DOJOVAW, 2004), Clinical Management of Rape Survivors (WHO,
2005) and Sexual Assault Nurse Examiner protocols.
Note: For purposes of this document, the female pronoun will be used, but Peace Corps
recognizes that males can also be sexually-assaulted.
A. Resources
To effectively respond to the sexual assault of a Volunteer who requires a SAFE
performed by the PCMO, PCMOs should follow this Medical Technical Guideline and
Medical Technical Guideline 540 Guide for Clinical Management of Sexual Violence

TG 542
and TG 545 Sexual Assault: Mental Health Assessment and Care. Other resources
include:
IPS 3-13 Responding to Sexual Assault Policy
IPS 3-13 Procedures for Responding to Sexual Assault;
Legal Environment Survey (LES) for the country in which the assault occurred;
B. Peace Corps Medical Officer (PCMO) Responsibilities

The responsibilities of a PCMO when performing a SAFE are to:
Assure the Volunteers physical safety, privacy, and comfort during the exam
Maintain the supplies required for a SAFE
Document the Volunteers pertinent history and injuries
Maintain chain of custody of the SAFE contents/evidence
3. ADMINISTRATIVE PREPARATIONS FOR THE SAFE
PCMOs must be able to perform a SAFE on a Volunteer. Administrative preparations include

stocking unexpired SAKs, maintaining a Sexual Assault Go Bag and reviewing the steps
and rules regarding a SAFE.
A. Ordering & Maintaining Sexual Assault Kits (SAK)

PCMOs must ensure that they have an adequate supply of appropriate and unexpired SAKs
available for use by them or local examiners in the event of an assault. Each post must
maintain at least 1-2 unexpired SAKs from Sirchie (www.sirchie.com) #VEC100 in stock at
all times. Peace Corps posts are responsible for the inventory and purchase of these SAKs.
Keeping SAKs in stock allows Peace Corps the ability to provide an evidence kit to local
authorities to assist in evidence collection for a Volunteer case or in the event that evidence
must be collected by the PCMO .
All medical staff at post must know where the SAKs are stored and ensure that the kits have
not expired. SAKs can be obtained through the Overseas Support Specialist at Peace Corps
Headquarters Office of Administrative Services/Post Logistics and Support Division or
directly from the Health and Human Services Supply Service Center (HHS) (www.hhs.gov)
or SIRCHIE (www.sirchie.com. In an emergency, SAKs may also be available through the
RSO or Health Unit at the U.S. Embassy.
B. Sexual Assault Go Bag

PCMOs must maintain a Sexual Assault Go Bag that contains items listed in the Peace
Corps Sexual Assault Supply Checklist (TG 540 Attachment A) and SAK.
C. Basic steps and rules for Forensic Evidence Collection

Collect evidence as soon as possible but only at the time agreed by the Volunteer.
Obtain consent for the SAFE using the consent form within the SAK (Attachment A).
Systematically inspect, collect evidence, and photograph the areas of injury or
materials as evidence. Document your findings and evidence collected on TG 540

TG 542
Attachments D, E, and/or F as appropriate (Peace Corps Sexual Assault Exam for
Females, Males and/or Strangulation).
Clothing: torn or stained clothing should be documented, photographed, and
collected. Do not tear through or further damage existing rips, stains, or holes in
clothing. Avoid contamination by allowing only the victim to handle her clothing.
Submit all of the Volunteers clothing worn at the time of the assault.
Foreign material (soil, leaves, grass): the description of the material and where found
on the body should be documented , depicted on a pictograph, and collected.
Hair: loose hair should be documented where found and collected. Comb the pubic
hair over a sheet of paper (for possible material traceable to the assailant) and pluck
and store a few of the victims pubic hairs. Obtaining the hair root from pulled hair is
more accurate in determining DNA than cut hair. If victim cannot tolerate pulled
pubic hairs, then do not force and document on the exam form. Buccal swabs and
blood can be used to determine DNA.
Sperm and seminal fluid: swabs may be taken from the vagina, anus, mouth or from
the skin.
DNA analysis from blood, saliva, sperm: swabs of these substances can be submitted
to help determine assailants. Control blood and saliva samples can be taken from the
Volunteer to distinguish from foreign DNA.
All specimens must be completely dried before storage.
Only clean, unused paper storage bags, envelopes (without bubble backing), and
cardboard boxes should be used for storage.
Plastic storage bags should never be used for storage as this prevents drying and
promotes mold and specimen spoilage.
Air dry only. Do not place items in the direct path of sun, fans, or heat as these
elements will destroy the evidence.
The examiner should change gloves frequently.
Tampons and sanitary pads should be dried thoroughly.
Condoms found in the vagina or rectum should be removed, swabs taken of the
contents inside condom, and the condom should be set out to dry. Do not cut the
condom open to increase the drying process. Once dry, place in evidence envelope.
4. PCMO INSTRUCTIONS TO THE VOLUNTEER PRIOR TO A SAFE
1. Support the Volunteer in her choice to pursue evidence collection.
2. Depending on the circumstances of the incident, ask the Volunteer not to urinate,
douche, shower, bathe, rinse her mouth, brush teeth, or clean under her fingernails
before examination, if possible and as appropriate.
3. The Volunteer should not wash or dispose of the clothing worn at the time of the
assault. If the Volunteer chooses to change into fresh clothes before she is examined,
instruct the Volunteer to put all clothing worn at the time of the assault in a bag or
pillow case to bring with her.
4. Inform the Volunteer to bring an extra set of clothes in order to be able to change into
a fresh set of clothing to change into after the exam.

TG 542
5. Except in an emergency where treatment cannot be delayed or there is an imminent

threat of bodily harm, advise the Volunteer not to go to the hospital or police until
staff arrives to accompany her. Instruct the Volunteer to contact the PCMO if the
medical and/or safety condition changes before staff arrive.
6. Work with the Volunteer on who she would like to be with her for support (the
Sexual Assault Response Liaison, Volunteer peer, host country friend or staff
member) . Make arrangements for this support person to be with the Volunteer as
soon as possible. The Volunteer should not be left alone.
A. PCMO Prepares the Volunteer For The SAFE
1. Greet the Volunteer and relate to her that you are there to help her. Im here to help
you, examine you, and provide the physical and emotional support you need to get
through this situation. Im so sorry this happened to you. I want you to know that
what has happened to you is not your fault.
2. Explain to the Volunteer that having the PCMO conduct a SAFE in accordance with
U.S. law will not trigger an official investigation, but may preserve her ability to seek
prosecution in the U.S. should she change her mind and decide later on to report to
U.S. law enforcement authorities.
3. Explain to the Volunteer that the evidence collected will be stored by the PCMO
until transfer to the OIG and that no PII (including details of the sexual assault) will
be provided to OIG in connection with the SAFE unless and until the restricted report
is converted into a standard report. Evidence will be held for five years and then
destroyed. The Volunteer will be notified by the Office of Victim Advocacy before
the evidence is destroyed.
4. Explain what is going to happen during each step of the exam. If the Volunteer asks,
explain why it is important, what it will tell the examiner and how the PCMO will use
the information obtained during the exam to determine treatment and other
appropriate steps.
5. Reassure the Volunteer that she is in control of the pace, timing, and components of
the exam. Explain that she can refuse steps of the examination and continue with
other steps of the exam.
6. Ask the Volunteer who she would like to be present in the room serving as a
chaperone. A chaperone is required to provide support to the Volunteer and is bound
by confidentiality. A chaperone can be the SARL, medical assistant/secretary, or any
other person the Volunteer would prefer to have in the room for support.
7. Let the Volunteer know that she will be spending approximate ly 2-3 hours with the
PCMO.
8. Prepare equipment and supplies before the Volunteer enters the exam room.

TG 542
9. Open a sealed Sirchie #VEC100 Sexual Assault Victims Evidence Collection Kit (aka
SAK). Note the date and time as this is the date and initial time that should be on ALL
the specimens. Document on the top of the SAK box.
10. Review the SAFE consent form (inside the SAK) with the Volunteer. Let her know that
she can refuse any aspect of the examination and that she can delete references to these
aspects on the consent form. Once the PCMO is confident that the Volunteer understands
the consent form, ask the Volunteer to sign the consent. Do not perform the exam without
consent.
B. Obtains the History of Events from the Volunteer

1. Interview the fully-dressed Volunteer in the examination room using a calm tone and
maintaining eye contact.
2. Refer to TG 540, Section 5. D on how to obtain the history and document on the
Female or Male Sexual Assault Clinical Exam Form (TG 540 Attachments D or E).
3. Document what the Volunteer says exactly in quotation marks. Do not sanitize or
remove remarks such as slang, offensive, or derogatory statements.
4. Document steps taken by the Volunteer since the event. Have you bathed, urinated,
defecated, vomited, douched, brushed your teeth, consumed food or beverages, or
changed your clothes since the incident?
C. PCMO Collects Evidence Through the SAFE
1. Start with a visual inspection of the overall appearance and behaviors of the Volunteer
prior to the exam.
2. Assess the Vital Signs including pain level. Tell me where you hurt.
3. Initial primary assessment may reveal severe medical complications that need to be
treated urgently. These take precedence over evidence collection or the remaining part of
the exam. Such complications might include: extensive trauma to genitals, head, chest or
abdomen, neurological deficits, and/or respiratory distress.
4. Never ask the Volunteer to undress or uncover completely. Examine the upper body first,
then lower body providing a gown and cover throughout the exam.
5. Systematically examine the patients body. Look for findings that are consistent with the
history. Collect evidence as you go through the exam.
a. If available and at the discretion of the PCMO, Toluidine Blue Dye may be used for
better visualization of lacerations/abrasions. Toluidine Blue Dye 1% assists
examiners to detect lacerations/abraisons difficult to detect with the naked eye. Use of
Toluidine Blue Dye should be after swabs for DNA/evidence have been collected, but
during the genital examination.

TG 542
How to Use: Apply Toluidine Blue Dye by swabbing sparingly to the external
genitalia and perianal area with a cotton guaze pad or swab. After a few seconds,
gently wipe the stained area of skin with lubricating jelly. The lacerated or abraised
skin areas will attract the dye making it easier to visualize these wounds. Do not use
the dye on mucous membranes as it will not stain these areas.
Let the Volunteer know prior to application that the dye produces a mild sting.
Residual stain on wounds may cause stains on under garments subsequent to the
exam.
Deep blue stain is positive for injury. No stain or diffuse stain is negative for injury.
Photograph the stained area with permission of the Volunteer.
Ima ges from Sexual Assault: Victimization Across the Life Span. A Color Atlas.(2003).
b. Female Examination
After vital signs, examine her body in this order and describe any of the following
specific findings, collect swabs from mouth, vagina, and/or anus if pertinent to
history, and take photographs of findings with the Volunteers permission:
Hands and wrists: circular wounds or bruising, defense wounds, broken nails
Eyes and nose: petechial hemorrhaging
Mouth: inner aspects of lips, gums and palate (frenulum and hard palate often
areas of trauma). Collect swabs from buccal space.
Ears: behind pinna for bruising, breached ear drums (from slapping/punching)
Neck: signs of bruising, patterns of bruising or injury around the neck
Scalp: areas of hair missing, lacerations, bruising, or other tender areas
Torso: bruising (in different stages of healing?), lacerations, bite marks, other
injuries. Inspect areas of the body that would have been in contact with the
surface on which the assault occurred.
Outer thighs and lower legs: circular wounds around ankles, bruising
Feet: heel abrasions from being dragged
Genital area, anus, and rectum (in this order)All areas are subject to Tears,
Ecchymosis/bruising/contusion, Abrasions, Redness, Swelling (TEARS),
bitemarks, burns, and pain.
a) Mons pubis
b) Inside thighs: bruising from being held open or apart
c) Perineum
d) Labia majora and minora
e) Clitoris

TG 542
f) Urethra
g) Introitus and hymen (Examine by holding the labia at posterior edge between
index finger and thumb and gently pull outwards and downwards.) Describe
areas of bruising and tears as on the face of a clock (e.g. partial hymnal tear
at 3 oclock)
h) Vaginal vestibule/navicular fossa: hymenal tears can extend to the vaginal
vestibule /fossa navicularis
i) Posterior forchette: the most common site of injury showing bruising, tears,
and abrasions
j) Cervix: gently introduce a speculum lubricated with sterile water. Check the
cervix, vaginal walls, and posterior fornix for trauma, bleeding, and signs of
infection.
k) Aspirate or collect vaginal secretions on swabs. Sperm remain motile for
about three hours after ejaculation. Non-motile sperm has been found up to
19 days in the vagina.
l) Bimanual exam: only if indicated from the history and exam findings to assess
for abdominal trauma, pregnancy, or infection
m) Anus and rectum (inspect while she lies on her back with thighs pulled
towards her abdomen and arms around the back of her legs): note the shape
and immediate dilatation of the anus (>than 2cm gaping is significant for
recurrent anal penetration). Check for fissures, tears, bleeding, fecal matter
present on skin.
n) Rectovaginal exam: only if indicated to assess for trauma, recto-vaginal tears,
bleeding. Use an anoscope if possible.
c. Post-menopausal women have decreased hormone levels that can cause reduced
vaginal lubrication and friable vaginal walls. This population is at increased risk for
tears, injury and transmission of STIs and HIV. Ensure a well-lubricated speculum is
introduced into the vagina using sterile water to lubricate speculum. If she cannot
tolerate without better lubrication of the speculum, water-based lubricant may be
used as long as it is documented on the exam form.
d. Male Examination
After vital signs, examine his body in this order and describe any of the following
specific findings, collect swabs from mouth, genital area and/or anus if pertinent to
history, and take photographs of findings with the Volunteers permission:
All areas are subject to Tears, Ecchymosis/bruising/contusions, Abrasions, Redness,

Swelling (TEARS), bite marks, burns, and pain.
Scrotum: swelling, bruising, bite marks, pain
Testicle: assess for testicular torsion as this an emergency and requires
immediate surgical consultation
Penis (bitemarks, lacerations)
Periurethral tissue
Urethral meatus
Anus and rectum (inspect while he lies on his back with thighs pulled towards
his abdomen and arms around the back of his legs): note the shape and

TG 542
immediate dilatation of the anus.Check for fissures, tears, bleeding, fecal
matter present on skin.
Other considerations: Sexual history? Circumcised? Hematuria?
e. During the exam, use a Woods lamp or alternate light source (ALS) in a darkened room
to inspect for semen or saliva (illuminates white in a dark room). Examine the perineal,
inner thigh, abdomen, face and back with a Woods lamp to detect semen or saliva stains.
Swab any fluorescent areas with saline-soaked cotton swabs. Try to photograph the
illuminated areas and document on the pictograph.
f. OMIT DRAWING DNA BLOOD SAMPLES ASKED FOR IN THE KIT. These
samples require refrigeration of the SAK which can be unreliable in many of Peace Corps
overseas environments. DNA blood samples may be drawn at a later date if needed.
Label the blood tube envelope with OMITTED due to lack of reliable refrigeration
g. If the Volunteer refuses parts of the exam (e.g. hair pulling), write Volunteer unable to
provide a specimen at this time on the respective envelope.
h. Label each piece of evidence as you go including individual swabs, envelopes, etc. Each
label should include the PCVs name, date, initial time, area where collected and PCMO
initials.
i. Seal individual bags or envelopes by putting a piece of paper tape across the seams of the
paper envelopes or bags in which the evidence is being held. Write the Volunteers name,
date, initial time, area where collected and PCMO initials.
D. SAFE Documentation
1. Document the interview and exam findings in a clear, complete, objective, and non-
judgemental way.
Document history and findings on documents contained in the SAK.

2. Document findings without stating conclusions about the nature of the incident. It is
not the PCMOs responsibility to determine the legal finding of rape or sexual assault.
Document exactly what you see as a clinician (not what you think may have caused
the injury).
3. Use appropriate and standardized terms to document the history and findings:
Inappropriate Clinical Findings Appropriate Clinical Findings

Documentation Documentation
Rape; Sexual Assault Incident
Victim Volunteer
Alleged No substitute and dont use. Alleged can be
interpreted as meaning that the Volunteer
exaggerated or lied about the incident. e.g.
alleged rape, alleged assailant, etc.).

TG 542
Intoxicated, drunk, under the Slurred speech, staggered gait, unable to focus
influence eyes, pupils dilated, etc.
Refused care, non-compliant, Unable to provide a specimen at this time
uncooperative
Refused parts of the exam, Provided 4 pulled head hairs, provided 4 pulled
Refused to provide 25 hairs genital hairs.
pulled from head or pubis
Raped anally Anal trauma
Vaginal rape Vaginal trauma
Forced oral sex Oral trauma as evidenced by torn lower
frenulum and bruising on the hard palate
Blood Red liquid or thick substance found on clothing
or on skin. Can document as blood only if
PCMO sees the blood actively bleeding from a
wound. If Volunteer allows, take a photograph.
Seminal fluids White, crusty dried substance; sticky white
substance. Do not document as sperm, seminal
fluid or ejaculate.
Standardized Term Definition

Laceration/Tear Blunt force trauma to tissue that occurs from crushing impact
resulting in an open wound with irregular edges or margins.
Incision Disruption of skin with clear and clean demarcated edges.
Bruise/Contusion Skin is not broken with possible discoloration, swelling, &
pain.
Ecchymosis Irregularly formed hemorrhagic area of the skin. Color is blue-
black changing to greenish brown-yellow.
Petechiae Small purplish hemorrhagic spots on the skin or mucous
membranes; may be singular or multiple.
Puncture A wound deeper than it is wide and caused by a foreign object.
Wound Disruption of the skin.
Lesion Pathological in nature; usually not caused by trauma.
Bulls Eye Injury Patterned injury assuming the shape of the offending object;
pale center with a hypervascular or petechial surrounding area.
Patterned Shows specific repetition, patterned appearance or site of
wounds.
Classification Use accepted terminology wherever possible (see chart below)

Site Record the anatomical position of the wound(s).
Size Measure the dimensions of the wound(s).
Shape Describe the shape of the wounds(s). (Linear, curved, irregular,
crescent, patterned, circular)
Surrounds Note the condition of the surrounding or nearby tissues
(swollen, bruised, ecchymotic, petechial)
Color Observation of color is particularly relevant when documenting

TG 542
bruises, redness, burns.
Course Comment on the apparent direction of the force applied (e.g. in
abrasions).
Contents Note the presence of any foreign material in the wound (e.g.
sand, dirt, glass, fabric, hairs, exudate color and consistency).
Age Do not estimate or document age of wound, it is impossible to
accurately identify the age of a wound and great caution is
required when commenting on this aspect. Comment on
evidence of healing. Can document wound healing as
evidenced by approximated edges or bruises in various
stages of healing as noted by varied coloration. Scabs
present or granulation present.
Borders The characteristics of the edges of the wound(s) may provide a
clue as to the weapon used (e.g. ragged laceration, clean,
approximated edges)
Depth Give an indication of the depth of the wound(s); this may have
to be an estimate.
Tenderness/Pain Describe area or wound and level of tenderness and/or pain
from 1-10 (10 highest)
E. Photographing Evidence and Wounds

i. Ask permission to take photographs
ii. Use a 35 mmdigital camera with a macro lens (60mm to 105 mm with 1:1 ration
continuous focusing). Use a clean digital picture cartridge.
iii. Take one full length photograph showing face, clothes, and general appearance
iv. Take medium ranged photographs to get detail, as well as show perspective of where
the clothing is torn or wound is on the body.
v. Take close up photos with an ABFO ruler to show scale and actual size of wounds
and torn or stained clothing.
vi. Label all photos on the back with the date, initial time, Volunteers name, part of the
body and wound and PCMO initials.
vii. Put photos and the digital photo cartridge in the medical record as clinical references
for care. They may be subpoenaed for court purposes later.
F. Summary Chronologic Note

The summary note is a chron note in SOAP documentation format to recap the forensic
examination, the PCMOs assessment and the plan for the Volunteers continued care.
The original summary note should be put in the medical record with a copy in the SAK
along with the other documents.
G. Drug Facilitated Sexual Assault (DFSA)

The PCMO is not authorized to collect specimens (hair, urine, or blood) to ascertain if a
drug facilitated sexual assault occurred. The reasons for this are:
Lack of sophistication and/or validity of local laboratories
Any illegal substances found in the specimen could be used against the Volunteer
in the local court system.

TG 542
There is a high likelihood that DFSA drugs metabolize quickly and are not found
in the specimen.
There is no chain of custody for the specimen; therefore, the specimen is not
admissible.
H. SAFE KIT FINAL SEAL, STORAGE AND CHAIN OF CUSTODY
Instructions for Handling a Sexual Assault Kit (SAK)

1. Collect evidence by performing a SAFE using an unexpired SAK.
2. When the evidence collection is complete, place one copy of all completed and signed
forms (consent and examination) in the SAK. Seal the SAK with red integrity stickers
that come with the SAK.
3. Contact the OVA for a unique numeric identifier for this case
4. Complete the Chain of Custody Medical Personnel section on the top of the SAK Kit
and on any other envelopes that contain forensic evidence that did not fit into the SAK
(use TG 542 Attachment A-3 for evidence that does not fit in the SAK) :
a. Victims Name: Write the Volunteers name
b. Case Number: Unique Numeric Identifier
c. Attending Physician/Nurse: PCMO or MD who collected evidence
d. Hospital/Clinic: Write the name of the address (e.g. Peace Corps Niger Medical
Office)
e. Placed by: Write the PCMOs name
f. Kit Sealed by: Write the PCMOs name or the individuals name who sealed it.
g. Date/Time: Fill in date and exact time
5. Label all evidence that does not fit in the SAK with TG 542 Attachment A-3 Evidence
Label
6. Place the sealed SAK and any other envelopes that contain evidence that did not fit into
the SAK into another box, bag or padded envelope, seal the package, affix either a
standard report (TG 542 Attachment A-1) or restricted report (TG 542 Attachment A-2)
chain of custody label to the package and complete chain of custody information on the
package. Note that for both standard and restricted reports the unique numeric identifier
obtained from the OVA is to be used in lieu of the Volunteers name.
7. If the SAK must be stored in the posts medical office until it is sent to Headquarters, the
SAK must be stored in a secure location within the medical office that is accessible to a

TG 542
minimum number of staff - preferably only the PCMO that collected the evidence.
Preferred secure areas can include: a locked desk drawer or locked file cabinet in the
office of the PCMO that collected the evidence and that same PCMO is the only one with
the key. (The PCMO may have to give testimony that the SAK was not tampered with
while stored at the medical office).
Instructions for Handling a Sexual Assault Kit

From: TG 542 Attachment A-1
Standard Report
1. Obtain a unique alphanumeric identifier for the Volunteers SAK from the Office of
Victim Advocacy (OVA) and document unique alphanumeric identifier in Volunteers
medical file.
2. Attach a Standard Report Chain of Posession label (TG 542 Attachment A-1) to the outer
package. Fill out the form using the unique alphanumeric identifier. Do not use the
Volunteers name on the outside Chain of Possession label.
3. Contact OIG (202-692-2900, oig@peacecorps.gov) to determine the method for returning

the SAK to OIG at Headquarters. OIG will advise whether an investigator will pick up
the SAK from post, if it should be turned over to the RSO, or if the PCMO should send
the SAK to OIG via another avenue.
4. In the CIRS database associated with the Volunteer, record the date and time that the
SAK was either transferred directly to the OIG or RSO or sent from field to
Headquarters.
For Restricted Report

1. Obtain a unique alphanumeric identifier for the Volunteers SAK from the Office of
Victim Advocacy (OVA) and document unique alphanumeric identifier in Volunteers
medical file.
2. Attach a Restricted Report Chain of Possession label (TG 542 Attachment A-2) on the
outer package. Fill out the form using the unique alphanumeric identifier. Do not use
the Volunteers name on the outside Chain of Possession label.
3. Send the package as soon as possible to OIG. Label the package as follows:
Evidence Custodian
Peace Corps - Office of Inspector General
1111 20th Street NW, 5th Floor
Washington, DC 20526

TG 542
4. The package must be sent through an avenue in which there is a tracking number. The
order of preference for sending the SAK to OIG at Headquarters is:
a. Diplomatic pouch with pouch registry number
b. APO/FPO with tracking number
c. DHL/FedEx/UPS express courier service with tracking number
5. Notify OIG by email at oig@peacecorps.gov, providing the date, avenue (diplomatic

pouch, APO, etc.), and tracking number of the SAK. Copy the Lead Security Specialist
and the Director of the Office of Victim Advocacy on the notification email.
6. In the CIRS database associated with the Restricted Report, record the date and time that
the SAK was sent from field to Headquarters.
I. PCMO REGISTERED NURSE PRIVILEGES MEDICAL AND SAFE EXAM

Registered Nurse PCMOs who have successfully completed training on Technical Guideline
540 at Medical Overseas Staff Training(MOST) and who have been granted gynecological
exam privileges through the OHS Credentialing Committee as outlined in TG 605, may be
granted, at the discretion of the Chief Clinical Programs, standing order TG 540. If
granted TG 540 privileges, the RN PCMO may perform the medical exam to determine
medical care needs of the victim and perform the SAFE exam only if required by the Office
of Inspector General and Office of Health Services.
REFERENCES
Fuagno, Diana (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN. Director, End Violence
Against Women International. http://www.evawintl.org/about.aspx
Giardin, B.W., Faugno, D.K., Spencer, M.J. & Giardino, A.P. (2003). Sexual Assault:
Victimization Across the Life Span. A Color Atlas. St. Louis, MO: G.W Medical
Publishing.
Giardin, B.W., Faugno, D.K., Seneski, P.C., Slaughter, L. & Whelan, M. (1997). Sexual
Assault: Victimization Across the Life Span. A Color Atlas. St. Louis, MO: G.W Medical
Publishing.
Legal Environment Survey (LES), Office of Safety & Security. Please note that each country has
its own.
Office on Violence Against Women. (2004, September) A National Protocol for Sexual Assault
Medical Forensic Examination; Adults/Adolescents. US Department of Justice. NCJ
206554 http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
Rape, Abuse, and Incest National network (RAINN). (2009). Statistics. http://www.rainn.org/

TG 542
Sirchie. (n.d.). VEC#100 Exam and Consent forms and Sexual Assault Forensic Evidence
Collection Kits. http://www. sirchie.com
Washington DC Sexual Assault Nurse Examiners (SANE) Protocols. 2011.
World Health Organization (WHO). (2005). Clinical management of rape survivors: Developing
protocols for use with refugees and internally displaced persons (revised edition).
Geneva, Switzerland. http://www.who.int/reproductive-health/index.htm

TG 542 Attachment A-1
EVIDENCE COLLECTION KIT: Affix to outer container

Medical Personnel (Please Print)
CASE NUMBER:
EVIDENCE PLACED BY: Date/Time:
KIT SEALED BY: Date/Time:
CHAIN OF POSSESSION
Received From:
Received By:
Date: Time:
Record time in 24 hr notation
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Chain of Possession
September 2014 TG 542 Attachment A-1
EVIDENCE COLLECTION KIT: Affix to outer container

Medical Personnel (Please Print)
CASE NUMBER:
EVIDENCE PLACED BY: Date/Time:
KIT SEALED BY: Date/Time:
CHAIN OF POSSESSION
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Received From:
Received By:
Date: Time:
Chain of Possession
September 2014 TG 542 Attachment A-2
EVIDENCE LABEL FOR ITEMS THAT DO NOT FIT IN THE SAK
Victims Name:
Case Number:
Hospital/Clinic
Placed By:
Date: Time:
Victims Name:
Case Number:
Hospital/Clinic
Placed By:
Date: Time:
Victims Name:
Case Number:
Hospital/Clinic
Placed By:
Date: Time:
Victims Name:
Case Number:
Hospital/Clinic
Placed By:
Date: Time:
STEP 1 AUTHORIZATION FOR COLLECTION AND RELEASE OF
EVIDENCE AND INFORMATION
(HOSPITAL)
1,_ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , freely consent to

allow M.D., his medical and nursing
assistants and associates to conduct an examination to collect evidence concerning an alleged sexual
assault. This procedure has been fully explained to me, and I understand that this examination will include
tests for the presence of sperm and venereal disease, as well as clinical observation for physical evidence
of penetration of or injury to my person or both, and the collection of other specimens and blood samples
for laboratory analysis.
I fully understand the nature of the examination and the fact that medical information gathered by this
means may be used as evidence in a court of law or in connection with enforcement of public health
rules and law.
I do D do not D authorize the hospital and its agents to release the laboratory specimens, medical
records , and related information pertinent to this incident, inclduing any photographs, to the appropriate
law enforcement officials, and I herewith release and hold harmless the hospital and its agents from any
and all liability and claims of injury whatsoever which may in any manner result from the authorized
release of such information.
SIGNED: _ _ _ _ _ _ _ _ _ _ _ _ _ __
WITNESS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE: _ _ _ _ _ _ TIME:

ADDRESS:
PARENT OR GUARDIAN (IF APPLICABLE) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

ADDRESS :
HOSPITAUPHYSICIAN- (White Copy) KIT BOX - (Yellow Copy) LAW ENFORCEMENT - (Pink Copy)
SIRCHIE Products Vehicles Training CAT. NO. VEC101

STEP 13 ANATOMICAL DRAWINGS
VICTIM'S NAME
Mark and describe all bruises, scratches, lacerations, bitemarks, etc.
~\
Photographs taken? 0 Yes 0 No Forensic Odontologist consulted? 0 Yes 0 No

PELVIC EXAMINATION-Note all signs of trauma. Use a non-lubricated speculum when possible.
VULVA: __________________________________________
INTROITUS: - - - - - - - - - - - -
VAGINA: ___________________
CERVIX: __________________________,_____________
UTERUS: -----------------------------------
ADNEXA: --------------------------------------
HYMEN: ----------------------------------
RECTUM: ______________________________
ANUS: _________
Photographs taken? o Yes o No Forensic Odontologist consulted? 0 Yes 0 No

EXTERNAL GENITALIA EXAMINATION- Note all signs of trauma. i.e., bruises, petachiae, discharges, sphincter tone.
Also note any traces of lubricants or rectal soiling.
PENIS: ------- ----------------------------------

SCROTUM:
MEATUS: - - - - - - - - - - ---------------------------
GLANS: _____________________________________
TESTICLES: ______________________,_____________
PERINEUM: _____________________________________
RECTUM : _______________ ______________________
ANUS: __________________________________________
Physician's Signature Date
HOSPITAUPHYSICAL- (White Copy) KIT BOX-(Yellow Copy) LAW ENFORCEMENT-(Pink Copy)

SRCHIE Prcducts Vehicles Training CAT. NO. VEC113
STEP2 VICTIM'S MEDICAL HISTORY AND ASSAULT INFORMATION
(PLEASE PRINT)
1. Victim's Name: - - - -- - - - - - - - - - - -- - -- - - - - - - - - - - - - - -
2. Date of Birth: _ _ _ _ _ __ 3. D Male D Female 4.Race _ _ _ _ _ _ _ _ _ _ _ _ __
5. Martial Status: D Single D Married D Separated D Divorced D Widowed
6. Date and time of alleged assault: _ _!_ _!__ __: _ _ am/pm
7. Date and time of the hospital examination: _ _! _ _! _ _ _ _:_ _am/pm
8. Examining physician: _ _ __ _ _ __ _ _ _ __ 9. Nurse: _ _ _ _ _ _ _ _ _ _ _ _ _ __
10. Prior to evidence collection, patient has::
D Bathed/Showered D Used Mouthwash D Defecated
D Douched D Changed Clothes D Vomited
D Brushed Teeth D Urinated D Drunk
Attempted Successful Ejaculation Yes No Unsure
11. Was there penetration of the: Vagina D D D D D D
Anus D D D D D D
Mouth D D D D D D
12. Oral/Genital Sexual Contact: D Fellatio D Cunnilingus
13. Did assailant use: D Lubricant DCondom D Insert foreign object(s) _ _ _ _ _ _ _ _ _ __
YES NO
14. Was the victim menstruating at the time of the assault? D D
15. Any consentual coitus in the last 72 hours? D D
If Yes, Date: and Time: _ _ _ __
If Yes , was a condom used? D D
16. Is the victim pregnant? D D
If Yes, duration of pregnancy _ _ _ _ _ _ _ _ __
17. Any injuries to the the victim resulting in bleeding? D D
If Yes, describe:
18. Number of assailants: - - - - - - -- - - - - - - - - - - - - - - - - -- -- - --
19 Raceof assailan~s)Hknown: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
20. Assailant(s) relationship to victim:
D Stranger D Acquaintance D Relative (specify): - -- - - - - - - - - - - - - -- - --
21. Any injuries to the assailant(s) resulting in bleeding? D Yes D No D Unsure
If Yes, describe:
22. Was any medication taken by the victim prior to or after the assault? D Yes D No
If Yes, describe: - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - -
23. Was any coercion used? D Yes D No
If Yes, D Knife D Gun D Choke D Fists D Verbal Threats
DOther: - - - - - - - - - - - - - -- - - - -- - - - - - - - - - - - - - - - -
24. Emotional demeanor of the victim; i.e., crying, angry, agitated, lethargic, frightened, shocked , depressed, etc.
25. Description of the victims outward appearance; i.e., clothes torn, shoe(s) missing , etc. : _ __ _ _ _ __
26. Victim's description of the alleged assault:
Signature of Examining Physician Date
HOSPITAUPHYSICIAN (White Copy) KIT BOX - (Yellow Copy) LAW ENFORCEMENT - (Pink Copy)
SIRI:HE Produ~:ts Ve hicles Training CAT. NO. VEC102

Sexual Assault :Mental Health Assessment and Care
TG 545
Peace Corps
SEXUAL ASSAULT: MENTAL HEALTH ASSESSMENT AND CARE
1. PURPOSE
To provide evidence-based trauma-informed care that meets the emotional needs of

Volunteers who have been sexually assaulted. The vast majority of sexual assaults are
assaults on women, and for the purposes of this guideline the language used assumes that the
Volunteer is a woman. However, the same principles should be used when responding to a
sexual assault on a man.
2. BACKGROUND
The goals of Peace Corps mental health support to a Volunteer after an assault are to educate
the Volunteer on post-assault reactions including acute stress disorder (ASD) and Post
traumatic stress disorder (PTSD), inform Volunteers about what promotes post-trauma
recovery, provide support options, and develop clinical care treatment plans.
Technical Guideline 540 Clinical Management of Sexual Violence, provides background

information concerning sexual assaults and describes the medical procedures, and mental
health screening appropriate in managing reported assaults. This guideline provides more
specific information on the emotional support of victims of sexual assaults.
PCMOs receive training on how to clinically support a Volunteer who has been a victim of
sexual assault. PCMOs should maintain their support skills by attending continuing education
events and consulting with the Counseling and Outreach Unit (COU). After a sexual assault,
the Volunteer may seek out someone she trusts and from whom she expects to receive
support. Any sexual assault case brought to Peace Corps attention requires the PCMO be
involved to support and assess the Volunteer. It is strongly advised that Volunteers who
report a rape be accompanied at all times unless the Volunteer requests to be alone.
Volunteers should be provided psycho-education about normal traumatic stress reactions and
the recovery process as early as possible. They should be encouraged to allow PC staff to
monitor their progress coping with the assault.
The Volunteer should be encouraged to regain control of her life. In fact, most individuals
have strong reactions in the immediate aftermath of a trauma; most display the symptoms of
posttraumatic stress disorder in the first days post-assault. These reactions are normal, and
naturally lessen over time without mental health treatment (Rothbaum, Foa, Riggs, Murdock,
& Walsh, 1992; Steenkamp, Dickstein, Salters-Pedneault, Hofmann, & Litz, 2012). The recommended
early and repeated assessments of Volunteers post-assault reactions is a collaborative way to
track and facilitate recovery.
When a Volunteer feels recovery is taking longer than she is comfortable with, evidence-
based trauma-focused intervention through Peace Corps should be provided. For the rape
victim, effective trauma treatment will enable her to move beyond the event and get back to
her own life in a relatively brief period of time, usually two to three months time or quicker
Office of Health Services September 1, 2013 Page 1

TG 545
(Foa, et al., 2007; 2009; Resick & Schnicke, 1993; Resick et al., 2002; Resick et al., 2008).
The Volunteer
should be encouraged to speak with a licensed mental health professional with specific
evidence-supported trauma treatment expertise.
Many Volunteers are worried about what to say and how to handle the reactions of people
who know about their experience. The utmost care must be taken in observing medical
confidentiality and in respecting the privacy of the Volunteer. PCMOs play a role in
providing education to all non-medical staff involved of the confidentiality requirements.
3. PCMO RESPONSIBILITIES
The PCMOs responsibility is to attend to the immediate emotional and physical needs of
the Volunteer. The PCMO should:
Assure the Volunteers physical safety and help her gain a sense of control.
Provide psychological support through a warm, non-judgmental approach.
Offer calm acceptance of the Volunteers range of feelings, and provide psychoeducation
about post-trauma reactions, including reassurance that whatever the reactions are, the
Volunteer will be supported and helped.
Help the Volunteer identify people and things that she would find supportive and
comforting.
If a sexual assault forensic exam (SAFE) is to be performed through an official SAFE
facility in-country, accompany and support the Volunteer to and during the exam.
After any SAFE is performed, evaluate the Volunteers psychological and physical
condition. Refer to Technical Guideline 540 Clinical Management of Sexual Violence.
Offer counseling through medevac (to Washington, DC or home of record), by phone by
COU, or with a mental health provider in country who has specific evidence-supported
trauma treatment expertise. The Volunteer may decline medevac or counseling at this
time. (See below.)
Maintain medical confidentiality.
Maintain clinical notes regarding emotional support and counseling in a separate Sexual
Assault Medical record to attach to the regular Volunteer health record (See TG 540).
4. PREPARING TO PROVIDE MENTAL HEALTH SUPPORT
The PCMO must plan ahead in order to address the emotional needs of Volunteers who have
been victims of sexual assault. The PCMO should:
Identify locally trained counselors willing to complete specific online training (course
information provided by Peace Corps) in trauma-focused treatment; this will enable
them to meet Peace Corps standard for managing sexual assault survivors mental
health care (i.e., provide evidence-supported trauma-informed treatment);
Follow-up with the locally trained providers to identify those who have completed
recommended training, and are therefore ready to manage mental health care for
cases of sexual assault;

TG 545
Familiarize yourself with TG-545, especially the symptoms and assessment tools of
Acute Stress Disorder and PTSD.
Attend Peace Corps-sponsored and other continuing medical education avenues to
keep general counseling skills relevant, and to update knowledge and skills regarding
best practices for responding to sexual assault and other survivors;
Maintain psychoeducational material in the office on traumatic stress reactions, what
facilitates recovery, and services available to the Volunteer.
5. INITIAL MENTAL HEALTH SCREENING AFTER SEXUAL ASSAULT
Rape appears to be more likely than other traumatic events to result in PTSD (Frazier, Byrne, Glaser,
Hurliman, Iwan, & Seales, 1997; Kessler, 1995; Kilpatrick, Edmunds, & Seymour, 1992; Kilpatrick, Saunders,
Amick-McMuillan & Best, 1989; Ullman & Filipas, 2001). (The purpose of the initial mental health
screening after a sexual assault is to normalize post-trauma reactions and to identify individuals
most at risk for developing PTSD (Gartlehner, et al., 2013)). It is normal for individuals to have
strong reactions in the immediate aftermath of an assault. More severe reactions are predictive of
post-trauma difficulties (Rothbaum, et al., 1992; Steenkamp, et al., 2012) .
The screening assessment begins to determine severity of reactions. It is a means for quantifying
traumatic stress reactions, and one way to attempt to identify potential problems in emotional
recovery post-assault. The screening process begins one of several opportunities to discuss and
educate the Volunteer on several topics: stress reactions, what facilitates recovery, and services
available to the Volunteer to support recovery.
Proactive discussion of emotional responses after an assault normalizes reactions, and gives
permission to the Volunteer to share concerns about her reactions. This also promotes recovery:
it discourages avoidance of memories, thoughts and feelings about the rape and denial of
psychological reactions; at the same time, it communicates acceptance of the Volunteer, her
experience, and her struggle to recover from the assault (Ehlers, Mayou & Bryant, 2003; Halligan,
Michael, Clark, & Ehlers, 2003; Koopman, Classen & Spiegel, 1994; Resick, Monson, & Chard, 2010; Ullman &
Filipas, 2001; Ullman, Townsend, Filipas & Starzynski, 2007).
Please Note: Most survivors immediately post assault will screen positive (i.e. have symptoms of
PTSD); only a few will be at risk for PTSD long term (Gartlehner, et al., 2013). In the immediate
aftermath (from 24 hours to one month post assault) a positive screen means further mental
health assessment, including assessment of Acute Stress Disorder (ASD) is warranted.
First, perform an overall mental health assessment.
A. Mental Health Assessment

The Mental Health Assessment and ASD/PTSD Screening requires a PCMOs
observations and the Volunteers responses to a series of questions.
o Volunteers appearance (can choose all that apply): Neat/groomed; appropriate dress;
poor hygiene; under/overweight; poorly nourished
o Volunteers behavior (can choose all that apply): Un/Cooperative, relaxed, agitated,
aggressive, suspicious, guarded, preoccupied, withdrawn, evasive, bizarre, tearful,
nervous
o Volunteers speech: Normal, soft, mumbled, loud, slurred, hostile, pressured

TG 545
o Affect (can choose all that apply): Restricted, cold, flat, superficial, labile, giggly,
apathetic, ambivalent, tense, anxious, apprehensive, worried, afraid, panicked angry,
enraged, ecstatic, euphoric, irritable, sad, depressed, hopeless, worthless
o Mood: Ask, How are you feeling? Document the PCVs reponse in their exact
words with quotation marks.
o Suicidal: Ask, Do you have feelings of wanting to hurt yourself?
If yes, ask, Do you have a plan on how you would hurt yourself?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, rope, etc.)?
o Homicidal: Ask, Do you have feelings of wanting to hurt someone (e.g. assailant)?
If yes, ask, Do you have a plan on how you would hurt someone?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, etc.)?
o Thought Processes: goal-directed, goes off topic easily, vague, repeats self, illogical,
flight of ideas, gives minimal answers, cant find words, loose associations
o Hallucinations: olfactory, tactile, visual, auditory, gustatory
o Delusions: Control, persecution, sexual, grandeur, religious, somatic
o Perceptions: Magical thinking, phobias, obsessive thoughts, impulse to perform
repetitive behaviors
o Orientation to person, place and time (do they know who they are, where they are,
and the date/time).
o Consciousness: clear, clouded, delirious, comatose, drowsy, lethargic/intoxicated
Second, assess for acute traumatic stress symptoms, acute stress disorder, and post traumatic
stress disorder in this order as assessment results indicate. Use the following assessment tools for
this purpose.
B. Assessing for General Acute Stress Symptoms, Acute Stress Disorder, and Post
Traumatic Stress Disorder
The PC-PTSD screening instrument (PC-PTSD; Prins, et al., 2003) is a good tool to use
in the INITIAL screening for posttraumatic stress reactions because it is short, it covers
the basic groups of posttraumatic stress reactions, and works well as a springboard for
discussion of the Volunteers emotional response to the assault. As you ask the questions
on the PC-PTSD screen, help the Volunteer understand these reactions, provide psycho-
education about stress reactions, and explore her experience of each symptom she
endorses.
1) Administer the Primary Care PTSD Screen (PC-PTSD)

a. Use the PC-PTSD to determine if the Volunteers reactions are in response to the
assault for which they are seeking care.
b. If the assault is recent, then alter the timeframe on the screening instrument (e.g.
if the assault happened last week, ask the Volunteer, In the past week, have you
had.(symptoms)?
c. Tell the PCV that you are going to administer a few questions that will help
determine the severity of the Volunteers reactions to the assault. This screening
tool is used by primary care clinicians to assess if a person may need extra
emotional support after a traumatic event.
d. You may either ask the questions by phone or in person or ask the Volunteer to
complete the instrument herself.

TG 545
Primary Care PTSD Screen (PC-PTSD)
The PCMO should ask: In relation to this event:

Have you had nightmares about it or thought about it when you did not Yes or No
want to?
Tried hard not to think about it or went out of your way to avoid Yes or No
situations that reminded you of it?
Were constantly on guard, watchful, or easily startled? Yes or No
Felt numb or detached from others, activities or your surroundings? Yes or No
e. Scoring: A score of 3 yes responses or greater means the Volunteer has

screened positive for PTSD.
i. During the first days and weeks posttrauma, this can be considered
normal. If the Volunteer displays more symptoms, severe distress in
additon to a positive PC-PTSD score, and it has been less than a month
since the assault, assessing for Acute Stress Disorder (ASD) may be
warranted. (Refer to Section 2 Assess for Acute Stress Disorder
below).
ii. A positive PC-PTSD more than a month since the assault, indicates a
need to assess for PTSD (Refer to Section 3 Assess for Post
Traumatic Stress Disorder below).
f. Regardless of the score, use the PC-PTSD tool to provide psychoeducation about
traumatic stress reactions and natural recovery.
g. For PC-PTSD scores of 3 or greater, the PCMO should seek consultation from
COU on how to support the Volunteer.
h. Ask Volunteer if she would like to consult with a counselor in COU directly.
2) Assess for Acute Stress Disorder

Acute Stress Disorder represents a stronger posttrauma response than most survivors
experience. Meeting diagnostic criteria for ASD in the first month post trauma is
associated with later meeting criteria for PTSD (Brewin, Andrews, Rose & Kirk, 1999).
For this reason, it is important to assess for ASD among survivors with a positive
PC-PTSD screen who are also reporting intense distress. Individuals meet diagnostic
criteria in DSM-5 for ASD if they exhibit has 9 of the following 14 symptoms listed
below (APA, 2013).
1. Recurrent involuntary & intrusive 8. Efforts to avoid distressing memories,

memories of the trauma thoughts or feelings about or related to the
trauma
2. Recurrent distressing dreams of the 9. Efforts to avoid external reminders of the
trauma trauma (e.g., people, places, conversations,
activities, objects, situations) that arouse
distressing memories, thoughts or feelings
3. Dissociative reactions: flashbacks 10. Sleep disturbances
4. Intense or prolonged psychological 11. Irritable behavior and angry outbursts
distress or marked physiological (without provocation)
arousal reactions to internal or

TG 545
external reminders of the trauma

5. Persistent anhedonia 12. Hypervigilance (looking over ones
shoulder)
6. An altered sense of reality of 13. Concentration problems
surroundings or of oneself
7. Amnesia for important aspects of the 14. Exaggerated startle responses
trauma
8. Assess for Post Traumatic Stress Disorder

More than half of individuals who are sexually assaulted recover substantially and do
not meet diagnostic criteria for PTSD by three months post assault (Foa, et al., 2007,
Resick et al., 2002, Steenkamp, et al., 2012). However, as stated earlier in TG-545
(Sec. 5, paragraph 1), the trauma of rape is associated with high rates of lifefime
PTSD (Ullman & Filipas, 2001; Ullman et al., 2007; Rothbaum et al., 1992; Steenkamp et al., 2012).
Between one and three months post assault, many sexual assault survivors may still
struggle with their reactions to the assault.
a. Volunteers whose PC-PTSD score is 3 or greater and are one month post assault,
may be assessed for PTSD using a measure of PTSD symptoms such as the
PTSD Checklist (PCL; Weathers, et al. 1994) or PTSD Symptom Scale (PSS;
Foa, et al., 1993). This assessment provides a better sense of their reactions, their
frequency, severity, and type.
b. Volunteers who score in the PC-PTSD screen problem range (3 or greater),
should be provided more targeted education about what facilitates recovery after
an assault, and encouraged to talk with a COU therapist to get further information
about trauma reactions, recovery, and available treatments.
c. PCMOs should provide the Volunteer with written materials that highlight trauma
reactions, recovery, and available treatments.
6. SUPPORT IN THE IMMEDIATE AFTERMATH OF A SEXUAL ASSAULT
Recovery from sexual assault is a natural process (Bonanno, 2004; Ozer, et al., 2003). Between
50% and 80% of survivors of sexual assault recover without professional psychological help
(Rothbaum et al., 1992; Steenkamp et al., 2012). The length of time to recovery from a sexual
assault may vary, but most individuals who have been sexually assaulted resolve post-trauma
symptoms within about three months and do not meet criteria for a diagnosis of PTSD
(Resick, unpublished manuscript 2002; Rothbaum, et al., 1992; Steenkamp et al., 2012).
Immediate Support
The only evidence-supported immediate post assault care is that endorsed in the United
States Veterans Administration/Department of Defense Clinical Practice Guidelines (US
Department of Veterans Affairs, 2010). Notably, there is no research support for the
effectiveness of psychological first aid for preventing PTSD and there is evidence that
critical incident stress debriefing may be harmful (Gartlehner, et al., 2013).
To assist in the immediate aftermath of an assault the PCMO should:
Provide concrete help (e.g. food, warmth, and shelter) (US Department of Veterans
Affairs, 2010).
Soothe and reduce states of extreme emotion (US Department of Veterans Affairs, 2010).
Increase controllability (US Department of Veterans Affairs, 2010).

TG 545
o Support the Volunteer as being in charge of when, to whom, where she talks
about the incident and other aspects of her personal history. The Volunteer should
be in charge of her history and tell it as she is able.
o Provide good information and psycho-education can help survivors make the
decisions they need to make. She needs to regain control of her life, starting with
the small decisions, such as what to take with her to the capital and where to stay
o Assist the Volunteer in making her own decisions regarding whether she wishes
to work within her own support network on her recovery, or her interest and
readiness to accept professional help from a trauma expert.
o Offer medical evacuation to Washington or home of record for counseling,
recuperation, and management of the trauma in a safe and familiar environment
o Discuss options with her:
Does she want to go to Washington for additional medical or psychological
support?
Does she want her family or friends notified?
Is there another Volunteer in the country who is able to provide companionship
and support?
As she is able, discuss any concerns about returning to her site. Should other
sites be considered?
She may be considering using annual leave or early termination instead of
medical evacuation. Reassure her that she is in control of these decisions, and
that medevac may be the best way for her to get help after an assault.
Assist survivors to help manage distress (US Department of Veterans Affairs, 2010).
o Provide psycho-education about trauma reactions, recovery post-trauma, and what
is known about what facilitates recovery (i.e., talking through the experience,
allowing feelings, talking about ones thoughts about why it occurred, etc).
o Provide psycho-education about the availability of highly effective treatments for

Volunteers who may struggle with post-trauma recovery, and that these
treatments may be available by phone in-country from COU staff, or in person
with COU staff via medevac to DC.
o Offer emotional support, and professional counseling (locally or with COU) as

appropriate.
o Consult COU if distress symptoms warrant consideration of medication
o See section 10 of this TG for further information about managing post traumatic
stress during a clinical examination.
Assist survivors on how to manage the repetitive, compulsive need to understand why it
happened or to attribute fault. (US Department of Veterans Affairs, 2010).
o Do not label the incident anything other than what the Volunteer calls it. If she
does not think a rape took place, but her history reveals that it does meet the
definition, do not use the term rape unless the Volunteer does. You may help her
to consider how not calling it an assault affects her thoughts and feelings and help
her understand that what one calls an upsetting event can affect ones recovery.

TG 545
o Empathize with the Volunteer and do not imply blame.
Offer support to other Volunteers who may be experiencing guilt, anger, or anxiety in
relation to the assault.
Recognize that the sense of belonging to the Peace Corps community can be therapeutic.
Peace Corps affiliation is healing because it offers a group identity at a time when the
victims identity is temporarily shaken.
Psychological treatment in the immediate aftermath of a trauma
Psychotherapy in the immediate post-trauma period (i.e., first days up to one-month post-
trauma) may be helpful for some assault survivors. The available research evidence indicates
that the only psychological intervention shown to reduce post-trauma symptoms and help
prevent meeting criteria for PTSD at one-month post-assault is brief trauma-focused
cognitive behavior therapy (CBT) (Gartlehner, et al., 2013).
7. MEDICATIONS
**Consult with OHS before prescribing any psychotropic medications**
Use of benzodiazepines post-trauma is not recommended (Gartlehner, et al., 2013). Negative

effects of this class of medications for trauma reactions as well as anxieties in general far
outweigh any short term symptomatic relief. Anything but short-term use of benzodiazepines
increases the risk of PTSD (Gartlehner, et al., 2013). For this reason, consult with OHS
before prescribing any psychotropic medications.
Medications other than benzodiazepines better address symptoms associated with

traumatization. For example, Ambien for sleep onset difficulties and SSRIs for depressive
symptoms related to traumatic stress have fewer negative consequences (Bernardy, 2013;
Cates, et al. 2004; Cloos, 2010; Cloos & Ferreira, 2008; Department of Veterans Affairs,
2010; Lader, 2011; Mendelson, 2000; Perlis et al., 2005).
Please note, currently, there is insufficient evidence for the effectiveness of SSRIs in
comparison to Cognitive Behavioral Therapy to prevent PTSD (Gartlehner, et al., 2013).
8. ON-GOING MENTAL HEALTH ASSESSMENT AND SUPPORT
With the Volunteers permission, perform the PC-PTSD screening at these intervals to
assess for recovery status and to coincide with medical follow up testing:
Recommended Follow-up Services (if checked):
At 72 hours post assault:

PEP evaluation and tolerance (if PEP given)
Review of laboratory results (serum and cultures)
Assess mental and physical health
Perform a PC-PTSD
Give Hepatitis B booster

TG 545
At 2 weeks:
Repeat Pregnancy Test
Repeat Gonorrhea and Chlamydia test if symptomatic
CBC (if PEP given)
LFT (if PEP given)
At 4 weeks:
Perform a PC-PTSD.
HIV Test
At 8 weeks:
Repeat CBC and/or LFT if abnormal at 2weeks
Perform a PC-PTSD ( Can be done by phone if PCV not coming
into the office for medical testing.)
At 3 Months:
Serum test for Syphilis (VDRL or RPR)
HIV Test
Perform a PC-PTSD
At 6 Months:
HIV test
Hepatitis C Test
Perform a PC-PTSD
Research does not support encouraging the victim to repeatedly explain what happened
outside of the strict constructs of evidence-supported trauma treatment (Gartlehner, et al.,
2013) pp. 89, 96). Should the Volunteer express a desire to tell you, a trusted other or
writing about what happened may aid recovery. Volunteers should be encouraged to not
avoid thoughts, feelings and memories of the trauma.
Respect her wishes regarding the quality and quantity of communication with you.
Trauma experiences are often accompanied by feelings of grief and a sense of loss. The
Volunteer may have lost her sense of safety and security and may sense that shes lost her
way of life.
Encourage her to express all feelings regarding the assault, the assailant, and the
situation. Most reactions are understandable as related to traumatic assaults.
Recognize any fear, and respect it. Help her identify what is causing the fear, and
address any situations that still pose a threat. If fears are pervasive yet the Volunteer can
acknowledge she is not currently in danger, help her understand how fight/flight reactions
can fuel feelings of fear, and that this is normal and may persist for some time when
remembering the assault.
Recognize any feelings of anger and help her to identify its direction or target. Anger at
being helpless to prevent or stop the assault should be directed toward the assailant.
Volunteers who are distressed by their reactions may be offered a phone consult with a
therapist/trauma expert from COU. Explore this option the Volunteer at any timepoint in
the process.

TG 545
9. COMMON EMOTIONAL REACTIONS TO SEXUAL ASSAULT
The most widely studied psychological consequence of sexual assault is PTSD. Data from a
large study in the US that compared the effects of different types of traumas suggested that
sexual trauma is more likely to lead to PTSD than other types of trauma events (Kessler et al.,
1995). Kesslers study found that 45% of women who reported having experienced a rape met
criteria for having PTSD at some point in their lives; this was significantly higher than the 38.8%
rate among men who had experienced combat. Sexual assault is extremely difficult for men as
well: 65% of men who reported having experienced a rape met criteria for PTSD.
Symptoms of PTSD include re-experiencing the trauma, negative changes in mood or thoughts,
avoidance of situations associated with the trauma, emotional numbing, dissociative reactions,
and hyper-arousal. Perhaps the most dramatic trauma-related reaction medical providers may see
is dissociation.
Dissociation can involve a range of phenomena including altered awareness, attention to

flashbacks, or out-of-body experiences. Dissociative reactions may be triggered by a strong
emotional reaction such as terror, surprise, shame, or helplessness, or feeling trapped or exposed
Any of the symptoms of PTSD can be triggered in or around a medical setting. This is
particularly so in the immediate aftermath of a sexual assault, but may occur during routine
annual examinations too. Specific procedures such as dental, gastrointestinal, and gynecological
exams can potentially trigger a posttraumatic reaction in patients who have experienced sexual
trauma. In particular, pelvic exams, colonoscopies, endoscopies and other procedures that
involve placing an instrument into a bodily orifice may be sufficiently reminiscent of the sexual
trauma to evoke a posttraumatic reaction.
It is important to recognize that reactions to sexual assault vary. However, there are several
common ones that may recur for weeks or even months after the attack (APA, 2013). The
Volunteer should be provided psycho-education about post-trauma reactions, and factors that
promote and hinder post-trauma recovery. Again, please remember that most sexual assault
survivors recover within 3 to 4 months post-assault without professional intervention (Resick,
unpublished manuscript, Rothbaum et al., 1992; Steenkamp, et al., 2012).
Common post-trauma reactions include:
Recurrent disturbing memories.
Physical and emotional distress with memories.
Fears of many kinds
A need for continuous support from family or close friends.
Difficulty in sleeping, recurrent nightmares, intrusive thoughts about the event.
Negative thoughts about oneself and others.
Increased use of alcohol and/or drugs or other means to decrease intrusive thoughts of the
trauma.
Periods of depression or anger.
Feelings of guilt or shame.

TG 545
A sense of being damaged or unclean.

Feelings of paranoia that other people are talking about her or laughing at her.
Feeling spaced out or feeling distant or out-of-touch with herself.
10. MANAGING POST-TRAUMATIC STRESS REACTIONS DURING THE

SEXUAL ASSAULT EXAMINATION (Sharkansky, 2011).
Despite providers best efforts, sometimes posttraumatic stress symptoms occur during an
exam. If this happens, dont panic. Use grounding techniques with the patient:
Speak in a calm, matter of fact voice and avoid any sudden movements
Reassure the Volunteer that she is in a safe environment, and although she is having a
reaction, she will be okay.
Explain that you are examining her asking permission to continue the examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment..
11. PSYCHO-EDUCATION TO THE VOLUNTEER

Provide psycho-education about trauma reactions, recovery post-trauma, and what is
known about what facilitates recovery (i.e., talking through the experience, allowing
feelings, talking about ones thoughts about why it occurred, etc).
Provide psycho-education about the availability of highly effective treatments for
Volunteers who may struggle with post-trauma recovery, and that these treatments
may be available by phone in-country from COU staff, or in person with COU staff
via medevac to DC.
PC-PTSD Screening tool use and frequency of assessment
Provide the Volunteer with parameters to judge her own progress in recovering from
the assault, e.g., PTSD screening scores. The PCMO may consider directing the
Volunteer to a reliable website on PTSD treatment such as: www.ptsd.va.gov
Services available to the Volunteer
(Educational trifold under development)
11. PCMO SELF AWARENESS, RESPONSE, AND CARE

The PCMO should be aware of his or her own response to the Volunteer who has been
sexually assaulted:
Understand the differences in how the PCMOs culture and American culture define and
legally manage rape and sexual assault. Knowing ones own cultural biasesand keeping
them to oneselfis very important when working with traumatized individuals.
Common inappropriate responses are denial, downplaying the trauma, and telling the
Volunteer that things really arent so bad.
Another common inappropriate response to a Volunteer is to focus on what went wrong,
what she might have done differently or what mistakes she made. Explain to the

TG 545
Volunteer that people who respond in such a way probably do not mean to judge as much
as they need to deal with their own anxiety about the event.
Some may respond with criticism or judgment of the Volunteer. In particular, some men
may be dealing with their own anxiety about the aggressive use of sexuality by members
of their own sex. Men who are able to respond with sensitivity and understanding may
have a particularly helpful effect in providing support.
When working with a Volunteer, if the PCMO senses culture is interfering with
understanding of the situation or the ability to comfort the Volunteer, the PCMO should
feel free to (and be encouraged to) connect the Volunteer to COU for a consult. High
distress can exacerbate cultural and language differences straining communication and
the patient-provider relationship.
Take care of yourself. Recognize how hard it is to provide this kind of support and care.
Be sure to allow yourself some space, distance and support when managing a sexual
assault. Be informed about the effects of vicarious trauma.
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civilian version (PCL-C). Boston, MA: National Center for PTSD.

Peace Corps
A RESOURCE GUIDE FOR THE CLINICAL MANAGEMENT
OF SEXUAL VIOLENCE
TABLE OF CONTENTS
1. Purpose
2. Background
Classifications, Resources, Statistics
Peace Corps Commitment to Sexual Assault Victims
3. PCMO Responsibilities
4. PCMO Administrative Preparations to Manage Sexually-Assaulted Volunteers
Training
Host Country Law and Resources Regarding Sexual Assault
Ordering and Maintaining Sexual Assault Kits (SAK)
Sexual Assault Medical Records
5. Managing the Initial Report of a Rape
Initial Assessment
Preparing the Volunteer for a Sexual Assault Examination by the PCMO
6. History Taking and Clinical Examination
Taking the History
Performing and Documenting the Clinical Exam
7. Standing Order Sets
Prevention of Pregnancy
Prevention of Sexually-Transmitted Infections
Drug Facilitated Sexual Assault (DFSA)
8. Discharge Information
Discharge Information and Instructions for Volunteers
127s for Close of Service
Sexual Assault Discharge Summary
9. Registered Nurse PCMO Privileges for Sexual Assault
10. Addendums
a. Preparations List
b. Guidelines for Responding to Rape and Sexual Assault Algorithm
c. Sexual Assault Exam Form
d. Sexual Assault Clinical Exam Form for Females
e. Sexual Assault Clinical Exam Form for Males
f. Strangulation Addendum
g. Instructions for Completing the Examination Forms
h. Standing Order Set and Medical Treatment Plan
i. Discharge Information and Instructions for Volunteers
j. Summary Chronologic Note Outline
k. SAFE Consultant Information Form

TG 540
Management of Sexual Violence
1. PURPOSE
To establish procedures to provide trauma informed clinical care to Volunteers who have been
sexually assaulted. For guidance in meeting the emotional needs of Volunteers who have been
sexually assaulted, refer to Medical Technical Guideline 545 Sexual Assault: Counseling.
2. BACKGROUND
Sexual assault is a traumatic event that can be physically and psychologically devastating. Peace
Corps Medical Officers (PCMOs) are designated staff at post, and are generally first responders
to Volunteers who are victims of sexual assault. PCMOs are part of a Peace Corps system that is
prepared to respond immediately, effectively, and compassionately to victims. The clinical
components and approaches to examining and providing care to victims of sexual assault outlined
in this Technical Guideline are based on A National Protocol for Sexual Assault Medical Forensic
Examinations: Adults/Adolescents (DOJOVAW, 2004), Clinical Management of Rape Survivors
(WHO, 2005), Sexual Assault Nurse Examiner protocols, and Peace Corps Restricted Reporting
policy.
A. Classifications and Definitions
Peace Corps Sexual Assault Classifications according to CIRG, 2013:
Rape: The penetration, no matter how slight, of the vagina or anus with any body part or object,
or oral penetration by a sex organ of another person, without the consent of the Volunteer.
Aggravated sexual assault: Another person, without the consent of the Volunteer, intentionally or
knowingly:
(a) touches or contacts, either directly or through clothing, the Volunteers genitalia, anus,
groin, breast, inner thigh, or buttocks;
(b) kisses the Volunteer;
(c) disrobes the Volunteer; or
(d) causes the Volunteer to touch or contact, either directly or through clothing, another
persons genitalia, anus, groin, breast, inner thigh, or buttocks, or attempts to carry out any
of those acts, AND:
The offender uses, or threatens to use, a weapon OR
The offender uses, or threatens to use, force or other intimidating actions OR
The Volunteer is incapacitated or otherwise incapable of giving consent.
Sexual assault: Another person, without the consent* of the Volunteer, intentionally or
knowingly:
(a) touches or contacts, either directly or through clothing, the Volunteers genitalia, anus,
groin, breast, inner thigh, or buttocks,
or
(b) kisses the Volunteer on the mouth,
or
(c) attempts to carry out any of those acts.

TG 540
Management of Sexual Violence
*Consent means words or actions that show a knowing and voluntary agreement to engage in
mutually agreed-upon activity. Consent is absent if force has been used against the
Volunteer, the Volunteer has been threatened or placed in fear, or the Volunteer is
incapable of appraising the nature of the conduct or is physically incapable of declining
participation in, or communicating unwillingness to engage in, that conduct.
The Peace Corps defines restricted reporting to mean a confidential report made to designated
staff by a Volunteer who is sexually assaulted during service in order to receive restricted
report services without further disclosure of the Volunteers PII or details of the sexual
assault except to the extent necessary and without automatically triggering an official
investigation (IPS3-13).
Designated Staff refers to PCMOs, Sexual Assault Response Liaisons (SARLs), Safety and
Security Coordinators (SSCs), a Victim Advocate in the Office of Victim Advocacy, and
Assigned Security Specialist for the Office of Safety and Security. Medical and
counseling staff at Headquarters may be provided with the Volunteers PII and details of
the assault for the procurement of victim services (IPS 3-13 Restricted Reporting).
Many of the procedures in this Medical Technical Guideline will be relevant for all types of
sexual assaults. However, certain procedures are determined by the nature of the event. In all
cases of sexual assault, the emotional needs of the victim should be cared for in accordance
with Technical Guideline 545 Sexual Assault: Counseling.
Note: For purposes of this document, the word Volunteer will be used to encompass both
trainees and Volunteers and the female pronoun will be used, although Peace Corps recognizes
that males can also be sexually-assaulted.
B. Resources
To effectively respond to the sexual assault of a Volunteer, PCMOs should follow this
Medical Technical Guideline and adhere to policies and procedures outlined in the
following documents:
Procedures for Responding to Rape and Sexual Assault;

Legal Environment Survey (LES) for the country in which the assault occurred;
Medical Technical Guideline 545 Sexual Assault Mental Health Assessment &
Support;
Volunteer Reporting of Sexual Assault IPS 3-13; and
Medical Technical Guideline 542 Sexual Assault Examination & Forensic Evidence
Collection, applies in circumstances when the PCMO may be authorized to collect
evidence.
C. Statistics
It is estimated that one in every six women in the United States has been the victim of an
attempted or completed rape during her lifetime (RAINN, 2009). About 1 in 33 men have
experienced attempted or completed rape in their lifetime (RAINN, 2009).

Management of Sexual Viole nc e
TG 540
It is the host countrys local judicial or legal systems responsibility to decide if the legal
definition of rape or sexual assault applies in a particular case. Regardless of how the law treats a
particular incident, if a Volunteer says that she has been sexually assaulted, she should be treated
as a victim of sexual assault for purposes of the Medical Technical Guideline.
Victims of sexual assault do not always present at the time of the incident, but may present at a
later date with incident-related symptoms (e.g., acute stress disorders, pregnancy, STD).
Individuals (men and women) who report that they have been sexually assaulted must be treated
in a compassionate, non-judgmental manner (see Technical Guideline 545 Sexual Assault:
Counseling.)
Typically, only 20 percent of assaulted victims have physical signs of abuse and less than 50
percent exhibit signs of trauma in the first 24 hours. Forty percent may never show signs of
trauma, but this does not mean that an assault did not occur. Victims of sexual assault are 3 times
more likely to suffer from depression, 6 times more likely to suffer from post-traumatic stress
disorder, 13 more times likely to abuse alcohol, 26 more times likely to abuse drugs and 4 times
more likely to contemplate suicide (RAINN, 2009).
D. Peace Corps Commitment to Sexual Assault Victims

The Peace Corps is committed to providing a compassionate and supportive response to
all Volunteers who have been sexually assaulted. To that end, the Peace Corps makes the
following commitment to our Volunteers who are victims of sexual assault.
1. Compassion. We will treat you with dignity and respect. No one deserves to be the
victim of a sexual assault.
2. Safety. We will take appropriate steps to provide for your ongoing safety.
3. Support. We will provide you with the support you need to aid in your recovery.
4. Legal. We will help you understand the relevant legal processes and your legal
options.
5. Open Communication. We will keep you informed of the progress of the case,
should you choose to pursue prosecution.
6. Continuation of Service. We will work closely with you to make decisions
regarding your continued service.
7. Privacy. We will respect your privacy and will not, without your consent, disclose
your identity or share the details of the incident with anyone who does not have a
legitimate need to know.
Peace Corps staff worldwide will demonstrate this commitment to the Volunteer through
our words and actions.
3. PCMO RESPONSIBILITIES
The general responsibilities of a PCMO when to prepare for and manage rape and sexual
assault are to:
Train Volunteers on information relating to sexual assault management in-country,
medevac options, and health care provider surveys.

TG 540
Maintain hard copy information of host country sexual assault medico-legal resources for
quick reference and to provide for temporary duty medical officers providing clinical care
coverage on a short term basis.
Identify and maintain professional relationships with facilities or host country providers
recognized in the host country to perform SAFE exams.
Provide orientation to community back-up providers to Attachment L, A Step-by-Step
Guide to a Sexual Assault Report By a Volunteer to the Medical Duty Phone.
Fulfill the duties as a designated staff member as outlined in IPS3-13, Volunteer
Reporting of Sexual Assault and The Guidelines for Responding to Rape and Sexual
Assault
Assess the Volunteers physical safety, which is a shared responsibility among
designated staff.
Maintain medical confidentiality.
Explain to the Volunteer the policies and procedures for Restricted Reporting of Sexual
Assaults, the option to make either a Restricted Report or a Standard Report, and the
services that are available to the Volunteer, as well as IPS 1-11 Immunity from Peace
Corps Disciplinary Action for Victims of Sexual Assault. Use The Volunteer Reporting
Preference Form
If the Volunteer wants to report to local law enforcement, explain the local procedures
regarding a Sexual Assault Forensic Examination (SAFE) and the potential for such an
exam to lead to a standard report.
Ascertain how the Volunteer wants to report an incident (Restricted or Standard).
If necessary, contact the OMS Sexual Assault Nurse Examiner (SANE), International
Health Coordinator (IHC), or Counseling and Outreach Unit staff for clinical consults.
Perform a mental status exam and Acute Stress Disorder/Post Trauma Stress Disorder
screening and arrange for appropriate psychological support (see Technical Guideline
545 Sexual Assault Mental Health Assessment and Support)
Document the Volunteers pertinent history, injuries, and care in a separate file labeled
SA (Sexual Assault) attached to the Volunteers general medical file.
Provides a choice of medical and mental health providers to the extent practicable including a
Health Care Provider/Consultant Satisfaction Survey to evaluate the providers
Develop a treatment plan in conjunction with OMS and the Volunteer according to the
mental and medical health needs of the Volunteer.
Arrange for a medevac upon the Volunteers request or if the PCMO determines a clinical
need for medevac (MS 264).
If the Volunteer is going to be medevacd ensure that the Volunteer understands that she may
request an escort. Normally the PCMO should serve as the escort unless this will create a
hardship for post. In this case the SARL or another staff member may serve as an escort.
Additional PCMO responsibilities specific to a Restricted Report:
Offer a clinical exam to ascertain medical and mental health needs for a treatment plan.
Treat physical injuries.
Provide medication for the prevention of sexually transmitted infections including HIV.
Note: **PCMOs should know local resistant strains of sexually transmitted infections
and identify appropriate alternative therapies in-country with OMS approval.**

TG 540
Provide medication for the prevention of unwanted pregnancy.

Notify the SSC and notify the SARL (if requested).
Notify the Victim Advocate (VA) if the Volunteer declines SARL services at post.
Notify the CD to report that an incident occurred without sharing any PII
Additional PCMO responsibilities specific to a Standard Report:
Notify the Country Director to coordinate a response plan with the CD serving as the
team lead.
Determine if the Volunteer wants to undergo a SAFE and explain its purpose, the process
for conducting an examination, who is authorized to conduct the exam in country, and
where it will be conducted. A SAFE may require notification to local law enforcement.
When legally permissible and when requested by the Volunteer, the PCMO should
accompany the Volunteer to and during a SAFE exam. If Volunteer declines a SAFE
exam, offer a clinical exam and medical treatment as for a restricted report.
If a SAFE is to be performed by an authorized local authority, the PCMO should refrain
from providing medical treatment to the Volunteer unless waiting for the SAFE may
compromise health care outcomes of the Volunteer (e.g. providing PEP, Plan B, or STI
prevention, frank wounds that need immediate attention). After the SAFE, the PCMO
should then develop the treatment plan to include STI and pregnancy prevention, medical
treatment of injuries, counseling, and medevac options.
Specific circumstance when the PCMO might conduct the SAFE:
For Volunteer on Volunteer or Staff on Volunteer Sexual Assaults, the incident may be
prosecutable under U.S. law. In cases that satisfy all of the following requirements, explain to
the Volunteer that there is a possibility that the crime could be prosecuted in the
U.S. and determine if the Volunteer wishes to have a SAFE conducted by the PCMO. The
requirements are:
The perpetrator is another Volunteer, a U.S. direct-hire Peace Corps staff member, a
U.S. citizen Peace Corps contractor (including a personal services contractor), or a
U.S. citizen embassy employee;
This incident is a rape or aggravated sexual assault; and,
The assault took place in a building or on land used by the U.S. government; or in
a residence used by a Volunteer, a U.S. government employee or other U.S.
government personnel.
If the Volunteer has expressed interest in reporting to law enforcement in the U.S., explain to the
Volunteer it would be necessary for the Volunteer to have a SAFE in accordance with U.S. law, rather
than host country law.
Refer to TG 542 for more information regarding the PCMO performing the SAFE exam.

TG 540
4. PCMO ADMINISTRATIVE PREPARATIONS TO MANAGE VOLUNTEERS WHO

HAVE BEEN SEXUALLY ASSAULTED
PCMOs must plan ahead to be able to clinically support a Volunteer who has been sexually
assaulted. Administrative preparations to assist PCMOs in preparing for management of
sexual assault are listed below. The PCMO must:
Participate in the facilitation of the required Pre Service Training Modules that outline:
o Services available to Volunteers including medevac options and health provider
surveys
o Where to go if assaulted
o Benefits from seeking medical care and emotional support, both immediate and long-
term
o Trust in the PCMO and management system
o Peace Corps protocols and policies regarding support to Volunteers who have been
victims of sexual assault
Know basic host country laws and policies regarding sexual assault:
o Participate in the development of the Legal Environment Survey especially portions
that pertain to the SAFE
o Complete the SAFE Consultant Information Form (Attachment K) and update
annually.
o Have a basic understanding of the legal requirements for reporting and for a SAFE
exam for evidence collection. Be able to explain the SAFEs purpose, the process
for conducting the SAFE, who is authorized to conduct the exam in country, and
where it will be conducted.
o Know if the PCMO can accompany and support a Volunteer during the SAFE exam
Identify and maintain relationships with local sexual assault health care resources:
o Official facilities and/or clinicians in country that perform SAFE exams
o Official arrangement with the local SAFE facility or official provider if possible
(recommended)
o Health care facilities for gynecological and general trauma
o Mental health care providers that work with sexual assault or trauma victims
o Laboratory services that can provide basic required laboratory analysis (e.g., CBC,
STI screening, and pregnancy testing) as well as laboratories that provide drug
screening.
o Infectious Disease specialists to know STI drug resistances in country
Maintain a readily accessible sexual assault resource binder in the medical office that
contains written protocols, guidance, and information regarding host country laws,
facilities, and resources. Post-specific information should be updated at least yearly.
o TG 540 Sexual Assault Management and attachments
o TG 542 SAFE and Forensic Evidence Collection
o TG 545 Sexual Assault Mental Health Assessment and Support
o Guidelines for Responding to Rape and Sexual Assault
TG 540
o Legal Environment Survey In-Country
o IPS 3-13, Volunteer Reporting of Sexual Assault and Reporting Preference Statement
o IPS 1-11, Immunity Policy
o MS 461
o Official or unofficial agreements with forensic examiners in-country
o Information regarding host country laws, facilities, and resources
o Post Incident Assessment Tool
Maintain Sexual Assault Kits (SAK) in the health unit

PCMOs must ensure that they maintain at least 1-2 unexpired SAKs from Sirchie
(www.sirchie.com) #VEC100 at all times. Peace Corps posts are responsible for the
inventory and purchase of these SAKs. Keeping SAKs in stock allows the Peace Corps
to provide an evidence kit to local authorities to assist in evidence collection for a
Volunteer case if the local authorities do not have such supplies in stock. All medical
staff at post must know where the SAKs are stored. SAKs can be obtained through the
Overseas Support Specialist at Peace Corps Headquarters, directly from HHS
(www.hhs.gov) or SIRCHIE (www.sirchie.com. In an emergency, SAKs may be
available through the RSO or U.S. Embassy Health Unit.
Maintain a Sexual Assault Go Bag that contains the following items to better respond
to a Volunteer away from the Peace Corps office setting:
o Items listed in the Peace Corps Sexual Assault Supply Checklist (Attachment A)
o SAK
o Sexual assault resource binder as outlined above
Maintain separable Sexual Assault Medical Records on Volunteers who are victims of
sexual assault.
o The PCMO should have materials on hand to develop a separable sexual assault
medical record for EACH incident.
o The first Sexual Assault File should be labeled SA/A. Subsequent files should be
labeled sequentially (e.g., SA/B, SA/C, etc.)
o The PCMO should staple the Sexual Assault Medical Record to the back of the
regular medical record.
o Documents that should be put in this record are:
Chronological SOAP notes and consultant reports related to the incident,
medical care, counseling, and medevac
the Reporting Option Form
Sexual Assault Clinical Exam Form
Clinical Order Set and Medical Treatment Plan
Discharge Summary Info for the Volunteer
Copies of reports from forensic examiners pertaining to the sexual assault.
Correspondence with the Office of Victim Advocacy, Office of Safety &
Security, Office of General Counsel, Office of Inspector General, or any other
Peace Corps staff directly related to health and safety of the Volunteer specific
to the sexual assault case.
Lab results specific to the sexual assault
o Example of separable Sexual Assault Medical Record

TG 540
LEFT SIDE OF SEXUAL ASSAULT RIGHT SIDE OF SEXUAL ASSAULT MEDICAL

MEDICAL RECORD (Top to Bottom) RECORD (Top to Bottom)
Post Service Documents related to the case Discharge Information and Instructions for Volunteers
Medevac Reports Chronologic Notes including Discharge Summary
Medevac Chronologic Notes from IHC Reports/Various Correspondence
Medevac Notes from COU/Counselors Clinical Order Sets and Treatment Plan
Correspondence between PCMO and HQ Sexual Assault Clinical Exam Form
regarding medevac Strangulation Addendum
Copy of Reporting Option Form
o In order to promote continuity of care, PCMOs should:

Document SA on the problem list in the regular medical record along with
date (s) in which the Volunteer consults with the medical office for care related
to the sexual assault. Do not use terms such as sexual assault, rape,
aggravated sexual assault in the problem list to identify the incident.
Document any diagnosis and need for follow up on the problem list as a result
from the sexual assault by identifying the diagnosis in conjunction with SA.
For example, SA/Pregnancy, SA/HIV+, SA/PTSD, SA/medevac to
Washington, DC
List any prescribed medications in the regular medical record where other
medications are listed.
Any immunizations given related to the sexual assault should be documented
on the immunization record in the regular medical record.
Maintain medical supply inventory in accordance with Peace Corps policy and
procedure for health unit medications prescribed to a Volunteer as a result of a
sexual assault.
5. CLINICAL MANAGEMENT
A. Managing the Initial Report of a Sexual Assault
1. Follow the Procedures for Responding to Rape and Sexual Assault
2. Refer to the Sexual Assault Notification Flow Chart (Attachment B)
3. Sexual Assaults should be considered a priority.
B. Initial Assessment
Assess Volunteers Vital signs and pain level. Respond to any acute injuries, trauma, and/or safety
needs of the Volunteer before performing a more thorough examination.
C. Preparing the Volunteer for the Clinical Exam and Obtaining Consent
(Sharkansky, 2011).
1. Greet the Volunteer in your office, and not the exam room (if possible), while she is still
fully dressed, and tell her that you are there to help her. Im here to help you, examine
you, and provide the physical and emotional support you need to get through this
situation. Im so sorry this happened to you. I want you to know that what has happened
to you is not your fault.

TG 540
2. Explain what is going to happen during each step of the exam. If the Volunteer asks,
explain why it is important, what it will tell the examiner and how the PCMO will use
the information obtained during the exam to determine treatment.
3. Reassure the Volunteer that she is in control of the pace, timing, and components of the
exam.
4. Reassure the Volunteer that the clinical exam findings will be kept confidential unless
she decides to revert to a standard report and pursue legal action.
5. Ask if she has any questions about the examination. Ask the Volunteer what she
imagines will be the most difficult parts of the examination. Listen carefully to any
concerns. Ask her what might help reduce her stress during the procedures. Provide the
Volunteer with as much choice as possible.
6. Ask the Volunteer who she would like to be in the room serving as a chaperone. A
chaperone is required to provide support to the Volunteer and is bound by
confidentiality. A chaperone can be the SARL, medical assistant/secretary, or any other
person the Volunteer would prefer to have in the room for support.
7. Discuss the exam consent form (Attachment C) with the Volunteer. Let her know that
she can refuse any aspect of the examination and that she can delete references to these
aspects on the consent form. When the Volunteer states she understands the consent
form, have her initial and sign.
8. Provide a secure, private location for the examination. During the exam, the only people
who should be in the room are the PCMO, the chaperone and/or SARL with the
Volunteer.
9. Perform the examination as soon as possible but only at the time agreed by the
Volunteer.
10. Do not force or pressure the Volunteer to do anything against her will. Explain that she
can refuse steps of the examination at any time but can still continue with other steps of
the exam.
D. Taking the History Using the Peace Corps Sexual Assault Clinical Exam Form
(Attachment D (Female) or E (Male))
1. Interview the fully-dressed Volunteer in the examination room.
2. Use a calm tone of voice and maintain eye contact. Speak clearly and directly to the
Volunteer. Do not stand over the Volunteer. Sit equal or lower than the level of the
Volunteer and begin gathering the medical history.

TG 540
3. Start by letting the Volunteer tell the history of events the way she wants to. Do not
interrupt. Explain that she does not have to tell you anything that she is not
comfortable with. Examples of appropriate interview questions:
a. Tell me what happened. Please tell me everything you remember about what
happened. Describe to me what happened in the best way that you can. I know
these are hard questions, but in order for me to understand the care you will need, I
need to ask you more details about this. I will go as fast as I can.
b. Please explain any involvement of your body (e.g. mouth, vagina, anus, and
breast).
c. Can you tell about what happened here (PCMO points to wound)?
d. Are there any parts of the incident that you have difficulty remembering?
e. Is there anything that I did not ask you that you would like to tell me?
f. Can you describe what you were thinking or feeling during the incident?
4. The patient may omit or avoid describing details that are particularly painful.
However, it is important for the PCMO to understand what happened in order to
guide the exam and care to be provided. Reassure the patient that the information is
for this purpose and will be kept confidential, and that you believe her account of the
incident. Take a break during the exam if necessary.
5. After the Volunteer relates the incident to the PCMO, the PCMO may question to
clarify information in a careful manner so as not to imply blame or lead to answers.
An example of a good way to clarify information:
I did not quite understand what you said about your mouth and ejaculation. Can you
tell me that again?
6. Do not ask questions that begin with why as they imply blame. Typical questions
that should be avoided:
a. What were you doing there?
b. Why did you go there?
c. Remember in PST when we discussed that letting a man into your home gave him
permission to have sex with you? Im sure he was confused with your
signals.
d. Were you wearing something that could have led the man on?
7. Asking about alcohol is sensitive and it is important not to imply blame. Tell the Volunteer
that the history of alcohol consumption is important especially when providing prophylactic
medications that may react adversely with alcohol. If the Volunteer shows signs of being
uncomfortable with the response to this question, reassure her that alcohol consumption will not
be used to accuse or blame her for the assault. Appropriate questions to ask:
a. When was the last time you had an alcoholic drink as this might affect the drugs or
treatment that I may offer you?
8. Take sufficient time to gather the information needed to focus the clinical exam.

TG 540
9. Except to help clarify information, avoid asking questions repeatedly or asking the
Volunteer to repeat her story unnecessarily.
10. Avoid distractions or interruptions during the history and exam.
11. Write precisely in the Volunteers own words including the history of events, threats
made against her and name(s) of assailant(s). Use qualifying statements such as:
Volunteer states or Volunteer reports Document what the Volunteer says
exactly in quotation marks. Do not sanitize or remove remarks such as slang,
offensive, or derogatory statements.
12. Review health record and confirm on-going health concerns, medications, vaccine
status, urological issues, and current STIs.
13. Evaluate for possible pregnancy by asking for details of current contraceptive use
(consistently and correctly), last menstrual period, last date of consensual sex and
contraceptive used at that time.
D. Perform and Document the Sexual Assault Clinical Exam (Attachments D:

Female, E: Male, and F: Strangulation)
1. Prepare equipment and supplies before the Volunteer enters the exam room.
2. Use the Sexual Assault Clinical Exam For (Attachment D: Female or E: Male) to
document the history and examination.
3. Explain everything you will do in advance and as you do it.
4. Listen carefully to any concerns voiced by the Volunteer.
5. Check regularly throughout the exam about the patients level of anxiety.
6. Engage in dialog during the exam.
7. Consider talking to her about her work or family because in some cases this kind of
distraction may help sexual assault survivors cope with distress of the post-assault
examination.
8. Utilize the Strangulation Documentation Form (Attachment F) if appropriate.
9. Help to minimize PTSD reactions during the examination. (Sharkansky (2011).
Despite providers best efforts, sometimes posttraumatic stress symptoms occur during
an exam. If this happens, dont panic. Use grounding techniques with the patient:
Speak in a calm, matter of fact voice and avoid any sudden movem ents

TG 540
Reassure the Volunteer that she is in a safe environment, and although she is
having a reaction, she will be okay.
Explain that you are examining her asking permission to continue the
examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment.
E. Document the Exam
Follow Instructions Form for Clinical Examination Form (Attachment G)
6. CLINICAL STANDING ORDER SET AND MEDICAL TREATMENT PLAN

The Clinical Standing Order Set and Medical Treatment plan (Attachment H) includes
standing orders for examinations, laboratory, and medications to manage sexual assault. The
Clinical Standing Order Set form reflects the requirements in this Technical Guideline. It
must be used for every sexual assault patient seeking clinical care from the PCMO and
completed as appropriate per the Volunteers clinical needs. The Clinical Standing Order
Form must be placed in the separate sexual assault medical file attached to the medical
record.
A. Prevention of Pregnancy
Pregnancy occurs as a result of rape in about five percent of female victims. Treatment to
prevent pregnancy should be offered to victims and prescribed only after a pregnancy test has
been performed to rule out prior pregnancy. Following are the recommended doses of oral
contraceptive pills to be taken within 72 hours of the incident. A follow-up pregnancy test
must be performed 10 to 14 days after emergency contraception given or after the incident if
emergency contraception is declined.
Protocol for emergency contraception

(Should be taken within 72 hours after unprotected intercourse, but may be effective for up
to 5 days; obtain a negative pregnancy test first.)
Plan B One Step 2 tablets containing levonorgestrel 0.75mg at once

OR
An alternative oral contraceptive that is used for emergency contraception. Refer to
package inserts on particular oral contraceptive for appropriate dosing.
AND PROVIDE
Tigan 200mg suppositories or oral (to be used 3-4 times a day for nausea, if required).

TG 540
B. Prevention of Sexually-Transmitted Infections

These post exposure prophylaxis protocols are based on the CDCs Sexually Transmitted
Diseases Treatment Guidelines, 2015. It is important to assess the Volunteers alcohol
intake within the last 72 hours before prescribing metronidazole or tinidizole to prevent
untoward affects from this alcohol-drug combination. PCMOs are responsible for
knowing drug-resistant strains of sexually-transmitted infections in their own
country and should consult with OHS regarding any changes to the treatment
guidelines provided below.
1. Chlamydia, Gonorrhea, and Trichomonas
Treatment for the prevention of chlamydia, gonorrhea, and trichomonas is indicated.

Recommended regimen to prevent gonorrhea, chlamydia, and trichomonas
Ceftriaxone 250 mg (diluted in Lidocaine 1%) IM in a single dose

AND
Azithromycin 1 gm orally in a single dose
OR
Doxycycline 100 mg orally 2 times a day for 7 days
AND
Metronidazole 2gm orally in a single dose
Note For Penicillin Allergic Volunteers: Treatment for the prevention of chlamydia,
gonorrhea, and trichomonas.
(For Gonorrhea)
Azithromycin 2 gm orally in a single dose
AND
(For Chlamydia)
If Azithromycin is not used in gonorrhea treatment, then 1 gm orally in a single dose
OR
Doxycycline 100 mg orally 2 times a day for 7 days
AND
(For Trichomonas)
Metronidazole 2gm orally in a single dose
2. Prevention of Hepatitis B
Rape victims who are non-immune to hepatitis B should receive prophylaxis against
hepatitis B. Unless the Volunteer has received a complete hepatitis B vaccine series or is
immune due to prior hepatitis B infection (serologically confirmed, see below),
vaccination should be provided. Hepatitis B Immune Globulin 0.06 ml/kg IM (HBIG,
human) can be given if available and offers additional protection.

TG 540
A HbsAb must be drawn on all rape cases to confirm Hepatitis B immunity.
If Volunteer is not immune give:

1) HBIG (0.06 ml/kg) IM x 1 dose; should be given as soon as possible after
exposure and within 24 hours if possible.
2) HB vaccine 1 ml (20 ug) IM at a separate site as soon as possible, but
within 7 days of exposure, with the second and third doses given 1 month
and 6 months, respectively, after the first.
Hepatitis B vaccine 1.0ml IM (deltoid) at months 0, 1, 6 post-exposure. Vaccination

should be given within 24 hours post-exposure if possible;
AND if available,
Hepatitis B Immune Globulin (HBIG, human) 0.06 ml/kg IM. Give in two separate
injections if volume of injection greater than 2.5 ml. Vaccination should be given as soon
as possible post-exposure.
3. Hepatitis C
Hepatitis C infection can be transmitted by sexual exposures, therefore test for Hepatitis C
antibody at 6 months after the exposure. Notify OMS of all positive results.
4. HIV
The risk of acquiring HIV infection as a result of rape depends on the likelihood of the
assailant having HIV, the sexual acts performed, and other factors (associated trauma,
presence of other STDs, etc.) According to the CDC, HIV sero-conversion has
occurred in persons whose only known risk factor was sexual assault or sexual abuse,
but the frequency of this occurrence is probably low. In consensual sex, the risk for
HIV transmission from vaginal intercourse is 0.1%0.2% and for receptive rectal
intercourse, 0.5%3%. The risk for HIV transmission from oral sex is substantially
lower. Specific circumstances of an assault (e.g., bleeding, which often accompanies
trauma) might increase risk for HIV transmission in cases involving vaginal, anal, or
oral penetration. Site of exposure to ejaculate, viral load in ejaculate, and the presence
of an STD or genital lesions in the assailant or survivor also might increase the risk for
HIV. Refer to TG 712, HIV Prevention and Treatment for further guidance.
Recommended HIV Post Exposure Prophylaxis:

Truvada (Tenofovir 300mg + Emtricitabine 200mg) 1 tablet orally QD for 28 days,
AND
Isentress (Raltegravir 400mg) 1 tablet orally BID for 28 days
Truvada carries a Black Box Warning indicating risk of hepatotoxicity and exacerbation of
Hepatitis B therefore it is imperative that HbsAg is drawn prior to prescribing Truvada.
C. Drug Facilitated Sexual Assault (DFSA)

The PCMO is not authorized to collect specimens (hair, urine, or blood) to ascertain if a
drug facilitated sexual assault occurred. The reasons for this are:
Lack of sophistication and/or validity of local laboratories
Any illegal substances found in the specimen could be used against the Volunteer
in the local court system
TG 540
There is a high likelihood that DFSA drugs metabolize quickly and are not found
in the specimen.
There is no chain of custody for the specimen; therefore, the specimen is not
admissible.
7. DISCHARGE INSTRUCTIONS
A Volunteer who has been a victim of sexual assault will need follow- up clinical care and
emotional support. The following documents should be provided to the Volunteer to educate,
reinforce, and promote compliance with post exposure prophylaxis care and follow- up.
A. Sexual Assault Discharge Information & Instructions for Volunteers Form
The Sexual Assault Discharge Information & Instructions for Volunteers Form
(Attachment I) should be used for follow-up care and instructions to inform Volunteers of
the treatment they have received and follow up clinical requirements.
B. 127-C Forms at Close of Service
Upon Close of Service, all Volunteers who have been treated or are currently undergoing
treatment for sexual assault must receive 127-Cs for counseling and any outstanding follow-
up clinical care and testing.
The PCMO should issue a 127-C for any outstanding sexually-transmitted infection testing or
pregnancy per instructions in this guideline and as appropriate.
For psychological support and counseling, the 127-C must be for a PhD psychologist or
psychiatrist with these instructions:
Provide three initial counseling sessions to provide support and evaluate for further
counseling needs. Call the Post Service Unit for additional sessions at 202-692-1540
opt.7.
C. SUMMARY CHRONOLOGICAL NOTE

The summary note (example in Attachment J) is a chronologic note in SOAP
documentation format to recap the clinical examination, the PCMOs assessment and the
plan for the Volunteers continued care. The summary note should be put in the separate
sexual assault medical file attached to the medical record.
8. PCMO REGISTERED NURSE PRIVILEGES MEDICAL AND SAFE EXAM

Registered Nurse PCMOs who undergone training on Technical Guideline 540 at Medical
Overseas Staff Training (MOST) and who have been granted gynecological exam privileges
through the Volunteer Support Credentialing Committee as outlined in TG 605, may be
granted, at the discretion of the Chief Clinical Programs, standing order TG 540. If
granted TG 540 privileges, the RN PCMO may perform the medical exam to determine
medical care needs of the victim and perform the SAFE exam as outlined in in TG 542.

TG 540
9. COMMUNITY BACK-UP PROVIDER COVERAGE INFORMATION REGARDING
SEXUAL ASSAULT MANAGEMENT
Community back-up providers must be provided information on how to manage a sexual

assault when providing clinical coverage to a post when the PCMO is not available for
coverage. A step-by-step guide to response is outlined in Attachment L, A Step-by-Step
Guide to a Sexual Assault Report by a Volunteer to the Medical Duty Phone. This
information can also be found in TG 185 Back up Healthcare Providers.

TG 540
REFERENCES
Centers for Disease Control (2015). Sexually Transmitted Diseases Treatment Guidelines, 2015.
http://www.cdc.gov/mmwr/pdf/rr/rr6403.pdf
Eisenhower Medical Center. (n.d.) Forensic Medical Report: Acute Adult/Adolescent Sexual
Assault Examination Form, Sexual Assault Exam Instructions, Strangulation Addendum.
Faugno, Diana (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN. Director, End Violence
Against Women International. http://www.evawintl.org/about.aspx
Guidelines for Responding to Rape and Sexual Assault. (2013). Office of Safety & Security,
U.S. Peace Corps.
Giardin, B.W., Faugno, D.K., Spencer, M.J. & Giardino, A.P. (2003). Sexual Assault:
Victimization Across the Life Span. A Color Atlas. St. Louis, MO: G.W Medical
Publishing.
Office on Womens Health. (2011, November 21). Emergency Contraception Fact Sheet. U.S.
Department of Health and Human Services.
http://www.womenshealth.gov/publications/our-publications/fact-sheet/emergency-
contraception.cfm#b
Office on Violence Against Women. (2004, September) A National Protocol for Sexual Assault
Medical Forensic Examination; Adults/Adolescents. US Department of Justice. NCJ
206554 http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., et
al. (2003). The primary care PTSD screen (PC-PTSD): Development and operating
characteristics. Primary Care Psychiatry, 9, 914.
Rape, Abuse, and Incest National network (RAINN). (2009). Statistics. http://www.rainn.org/
Sharkansky, E. (2011). Sexual trauma: Information for womens medical providers. National
Center for PTSD. Retrieved from: http://www.ptsd.va.gov/professional/pages/ptsd-
womens-providers.asp
Sirchie. (n.d.). VEC#100 Exam and Consent forms and Sexual Assault Forensic Evidence
Collection Kits. http://www. sirchie.com
Washington DC Sexual Assault Nurse Examiners (SANE) Protocols. 2011.

TG 540
Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994). The PTSD checklist
civilian version (PCL-C). Boston, MA: National Center for PTSD.
Weaver, Michael L. MD, FACEP, FCC. System VP Clinical Diversity and System Medical
Director, Forensic Care Program. Saint Lukes Hospital of Kansas City. mweaver@saint-
lukes.org
World Health Organization (WHO). (2005). Clinical management of rape survivors: Developing
protocols for use with refugees and internally displaced persons (revised edition). Geneva,
Switzerland. http://www.who.int/reproductive-health/index.htm

Peace Corps Medical TG 510 Mental Health

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Peace Corps Medical TG 510 Mental Health

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Peace Corps

Technical Guideline 510

MENTAL HEALTH ASSESSMENT AND SUPPORT

Evidence-based care is a multi-layered process (Figure 1). It promotes wellbeing by

3.2. Client/Population characteristics, needs, values, preferences and state of mind:

Office of Health Services July 2015 Page 1

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4.1. PCMO responsibilities

Guidance to PCMOs regarding response to Volunteer behavioral problems is beyond the

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4.4. Psychiatric emergencies: In the case of psychiatric emergencies, PCMOs should

5. EVIDENCE-BASED ASSESSMENT OF MENTAL HEALTH ISSUES

When conducted in a personalized and collaborative manner, mental health assessment is a

Office of Health Services July 2015 5

Compared to physical health problems, emotional distress is uniquely dependent on language.

Common assessment errors (Garb, 2010; Wilkinson, 2014)

Figure 2. Common assessment errors evidence-based assessments (EBA) seeks to avoid

Office of Health Services July 2015 6

The PROMIS-28 is an integral part of evidence-based mental health assessment.

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5.4. The mental status examination

6. PREVENTION OF MENTAL HEALTH PROBLEMS

6.1.The Personal Health Action Plan (PHAP):

6.2.The Alcohol Use Disorders Identification Test (AUDIT):

For more detailed information about the AUDIT, see TG 520.

6.3.The Patient Reported Outcomes Measurement Information System (PROMIS-28)

6.4.Additional prevention topics

Volunteers understanding of country safety and security issues

Office of Health Services July 2015 9

7.1.Distinguishing common adjustment problems from mental illness/ adjustment disorders

Common adjustment stressors in Peace Corps include:

1. Loss of ready access to HOR family, friends, community, lifestyle, amenities

Office of Health Services July 2015 10

Criteria for Adjustment Disorders, in brief, are:

In summary, considering onset, severity, and nature of a Volunteers problem, obtaining a

7.2.PCMO-provided supportive counseling for Volunteer adjustment issues

Supportive counseling expected of PCMOs is distinct from counseling or therapy provided

Professional mental health treatment by licensed professionals is a prescribed course of

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7.3. Integrating supportive counseling with evidence-based assessment and prevention of

Detailed information about the PROMIS-28 is in section 5 of this document.

7.4. When short-term supportive counseling by the PCMO is not enough

A short course of supportive counseling should be sufficient to address most common

Confidentiality is as important in supportive counseling as in other kinds of medical care.

7.6. Limits of confidentiality:

The sharing of medically confidential information is appropriate when the Volunteer

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B. Vol unteers psychological difficulties include ANY ONE of the following:

Figure 2. 2014 Proposed Criteria for Mental Health Referrals to OHS/COU

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A brief summary of Volunteers view of problem.

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9. IN COUNTRY MANAGEMENT OF NON-URGENT MENTAL HEALTH PROBLEMS

9.1. Using licensed mental health providers in country:

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9.2. Psychotropic medication management:

Psychotropic medications are commonly prescribed to treat a variety of psychiatric s ymptoms

Initiation of antipsychotics: Except in emergency situations, as covered in TG 530

Office of Health Services July 2015 19

9.3. Other mental health management issues:

Finally, PCMOs are responsible for the following:

Communicating/consulting with OHS/COU on Volunteer mental health concerns

9.4 Mental healthcare and the medical record

Office of Health Services July 2015 20

American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006).