KIT PENGUMPULAN

BARANG BUKTI KASUS KEKERASAN SEKSUAL

1. DIISI OLEH DOKTER PEMERIKSA/PETUGAS RUMAH SAKIT:

Nama korban :
Nama dokter :
Instansi/RS :
Barang bukti dikemas oleh
Nama :
Jabatan :
Tangga : / / jam :

2. DIISI OLEH PETUGAS KEPOLISIAN:

Diterima dari :
Tanggal : / / jam :
Penerima barang bukti:
Pangkat/NRP :
Jabatan :
Disegel oleh :
Pangkat/NRP :
Tanggal : / / jam :

3. DIISI OLEH PETUGAS LABORATORIUM:

Diterima dari :
Tanggal :
Penerima :
Nama :
Nomor polisi :
No.Reg Laboratorium:

NOMOR: 1

TATA CARA PENGGUNAAN

KIT KEKERASAN SEKSUAL
 NOMOR: 2

INFORM CONSENT DAN ANAMNESIS

KEKERASAN SEKSUAL

NOMOR: 3A PAKAIAN LUAR

NAMA : ___________________________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ___________________________________________________________________________________

JENIS BARANG : ___________________________________________________________________________________

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PAKAIAN LUAR TIDAK DIKUMPULKAN KARENA :

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_________________________________________________________________ TANDA TANGAN
_________________________________________________________________ PENGUMPUL BARANG BUKTI

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NOMOR: 3B PAKAIAN DALAM

NAMA : ___________________________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ___________________________________________________________________________________

JENIS BARANG : ___________________________________________________________________________________

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PAKAIAN DALAM TIDAK DIKUMPULKAN KARENA :

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_________________________________________________________________ TANDA TANGAN
_________________________________________________________________ PENGUMPUL BARANG BUKTI

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NOMOR: 3C BENDA ASING DISEKITAR TUBUH KORBAN

NAMA : ___________________________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ___________________________________________________________________________________

JENIS BARANG : ___________________________________________________________________________________

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BENDA ASING DISEKITAR TUBUH KORBAN TIDAK DIKUMPULKAN KARENA :

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_________________________________________________________________ TANDA TANGAN
_________________________________________________________________ PENGUMPUL BARANG BUKTI

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NOMOR: 4 KOTORAN DAN CAIRAN DISEKITAR TUBUH KORBAN

NAMA : _________________________________________________________________________
TGL / JAM : / / JAM : ______
DIKUMPULKAN OLEH : _________________________________________________________________________
JENIS BARANG : [ ] SPERMA KERING / BASAH
[ ] LUDAH KERING / BASAH
[ ] DARAH KERING / BASAH
[ ] KEROKAN KUKU
[ ] LAIN : _________________________________________________
TIDAK DIKUMPULKAN KARENA : _______________________________________________________________________
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___________________________________________________________________ TANDA TANGAN
PENGUMPUL BARANG BUKTI
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NOMOR: 5 SISIRAN RAMBUT KELAMIN KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

JUMLAH HELAI RAMBUT* : _______________ HELAI

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

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NOMOR: 6 CABUTAN RAMBUT KELAMIN KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

JUMLAH HELAI RAMBUT* : _______________ HELAI

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

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NOMOR: 7 SWAB DAN PULASAN VAGINAL KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

NB : *Simpan di wadah dalam keadaan kering suhu kamar

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NOMOR: 8 SWAB DAN PULASAN ANUS KORBAN

NAMA : ____________________________________________________________________
TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

NB : *Simpan di wadah dalam keadaan kering suhu kamar

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NOMOR: 9 SWAB DAN PULASAN MUKOSA PIPI KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

NB : *Simpan di wadah dalam keadaan kering suhu kamar

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NOMOR: 10 CABUTAN RAMBUT KEPALA KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

JUMLAH HELAI RAMBUT* : _______________ HELAI

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

NB : *Rambut dicabut dengan akarnya

Jumlah : Minimal 10 lembar
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NOMOR: 11 SAMPEL URINE KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

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NOMOR: 12 SAMPEL DARAH KORBAN

NAMA : ____________________________________________________________________

TGL / JAM : / / JAM : ______

DIKUMPULKAN OLEH : ____________________________________________________________________

TIDAK DIKUMPULKAN KARENA : _____________________________________________________________________

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TANDA TANGAN
PENGUMPUL BARANG BUKTI

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