Custom Sexual Assault Evidence Kits (Supply & Deliver)

Revised: 06/29/20 LMR 1 State of New Hampshire Date: 10/6/2020 Division of Procurement and Support Services Bureau of Purchase and Property Bid No.: 54-21 25 Capitol Street, Room 102, State House Annex Concord, NH 03301-6398 Date of Bid Closing: 10/26/20 Time of Bid Closing: 11:00 AM (EST) PLEASE DIRECT ANY QUESTIONS REGARDING THIS BID TO LORETTA RAZIN: E-mail Loretta.M.Razin@DAS.NH.GOV. EMAIL YOUR BID TO: NH.Purchasing@DAS.NH.Gov BID INVITATION FOR: Custom Sexual Assault Evidence Kits (Supply & Deliver) [Insert name of signor] _____________________________, on behalf of _____________________________ [insert name of entity submitting bid (collectively referred to as “Vendor”) hereby submits an offer as contained in the written bid submitted herewith (“Bid”) to the State of New Hampshire in response to BID # 54 -21 at the price(s) quoted herein in complete

accordance with the bid. Vendor attests to the fact that: 1. The Vendor has reviewed and agreed to be bound by the Bid. 2. The Vendor has not altered any of the language or other provisions contained in the Bid document. 3. The Bid is effective for a period of 180 days from the Bid Closing date as indicated above. 4. The prices Vendor has quoted in the Bid were established without collusion with other vendors. 5. The Vendor has read and fully understands this Bid. 6. Further, in accordance with RSA 21-I:11-c, the undersigned Vendor certifies that neither the Vendor nor any of its subsidiaries, affiliates or principal officers (principal officers refers to individuals with management responsibility for the entity or association): a. Has, within the past 2 years, been convicted of, or pleaded guilty to, a violation of RSA 356:2, RSA 356:4, or any state or federal law or county or municipal ordinance prohibiting specified bidding practices, or involving antitrust violations, which has not been annulled; b. Has been prohibited, either permanently or temporarily, from participating in any public works project pursuant to RSA 638:20; c. Has previously provided false, deceptive, or fraudulent information on a vendor code number application form, or any other document submitted to the state of New Hampshire, which information was not corrected as of the time of the filing a bid, proposal, or quotation; d. Is currently debarred from performing work on any project of the federal government or the government of any state; e. Has, within the past 2 years, failed to cure a default on any contract with the federal government or the government of any state; f. Is presently subject to any order of the department of labor, the department of employment security, or any other state department, agency, board, or commission, finding that the applicant is not in compliance with the requirements of the laws or rules that the department, agency, board, or commission is charged with implementing; g. Is presently subject to any sanction or penalty finally issued by the department of labor, the department of employment security, or any other state department, agency, board, or commission, which sanction or penalty has not been fully discharged or fulfilled; h. Is currently serving a sentence or is subject to a continuing or unfulfilled penalty for any crime or violation noted in this section; i. Has failed or neglected to advise the division of any conviction, plea of guilty, or finding relative to any crime or violation noted in this section, or of any debarment, within 30 days of such conviction, plea, finding, or debarment; or j. Has been placed on the debarred parties list described in RSA 21-I:11-c within the past year. This document shall be signed by a person who is authorized to legally obligate the responding vendor. A signature on this document indicates that all State of New Hampshire terms and conditions are accepted by the responding vendor and that any and all other terms and conditions submitted by the responding vendor are null and void, even if such terms and conditions have terminology to the contrary. The responding vendor shall also be subject to State of New Hampshire terms and conditions as stated on the reverse of the purchase order. Authorized Signor’s Signature _______________________________ Authorized Signor’s Title ________________________ NOTARY PUBLIC/JUSTICE OF THE PEACE COUNTY: ___________________________ STATE: ______________ ZIP: _________________ On the _____ day of _______________, 2020, personally appeared before me, the above named ________________________, in his/her capacity as authorized representative of ________________, known to me or satisfactorily proven, and took oath that the foregoing is true and accurate to the best of his/her knowledge and belief. In witness thereof, I hereunto set my hand and official seal. _________________________________________________________ (Notary Public/Justice of the Peace) My commission expires: _________________________________________________________ (Date) Form P31-A Unless specifically amended or deleted by the Division of Procurement and Support Services, the following General Terms and Conditions apply to this Bid and any resulting Purchase Order or Contract. mailto:%20Loretta.M.Razin@DAS.NH.GOV mailto:NH.Purchasing@DAS.NH.Gov Revised: 06/29/20 LMR 2 GENERAL CONDITIONS AND INSTRUCTIONS: NATURE OF, AND ELIGIBILITY TO RESPOND. This bid invitation is submitted in accordance with Chapter 21-1, and rules promulgated thereunder, and constitutes a firm and binding offer. A bid may not be withdrawn unless permission is obtained from the Bureau of Purchase and Property. Bids may be issued only by the Bureau of Purchase and Property and are not transferable. SAMPLES AND DEMONSTRATIONS. When samples are required they must be submitted free of costs and will not be returned. Items left for demonstration or evaluation purposes shall be delivered and installed free of charge and shall be removed at no cost to the State. Demonstration units shall not be offered to the State as new equipment. BIDS. Bids must be received at the Bureau of Purchase and Property before the date and time specified for the closing. Bids must be submitted on this bid form or exact copies and must be typed or clearly printed in ink. Corrections must be initialed. Bids are to be made less Federal Excise Tax and no charge for handling unless required by law. SPECIFICATIONS. Vendors must submit on items as specified. Proposed changes must be submitted in writing and received at the Bureau of Purchase and Property at least five (5) business days prior to the bid closing. Vendors shall be notified in writing if any changes to the specifications are made. AWARD. The award will be made to the responsible Vendor submitting a conforming bid meeting specifications at the lowest cost unless other criteria are noted in the bid. Unless otherwise noted, the award may be made by individual items. If there is a discrepancy between the unit price and the extension, the unit price will prevail. When identical low bids are received the award will be made in accordance with the Administrative Rules. Discounts will not be considered in making award but may be offered on the Invoice for earlier payment and will be applicable on the date of completion of delivery or receipt of Invoice, whichever is later. On orders specifying split deliveries, discounts will apply on the basis of each delivery or receipt of Invoice, whichever is later. PATENT INFRINGEMENT. Any responding vendor who has reason to believe that any other responding vendor will violate a patent should such responding vendor be awarded the contract shall set forth in writing, prior to the date and time of closing, the grounds for his belief and a detailed description of the patent. ASSIGNMENT PROVISION. The responding vendor hereby agrees to assign all causes of action that it may acquire under the antitrust laws of New Hampshire and the United States as the result of conspiracies, combinations, or contracts in restraint of trade which materially affect the price of goods or services obtained by the state under this contract if so requested by the State of New Hampshire. FEDERAL FUNDS. This Division of Plant and Property Management, under RSA 21-1:14, VIII shall assure the continuation or granting of federal funds or other assistance not otherwise provided for by law by following the Federal Procurement Standards. STATE’S OPTIONS: The Bureau of Purchase and Property reserves the right to reject or accept all or any part of any bid, to determine what constitutes a conforming bid, to award the bid solely as it deems to be in the best interest of the State, and to waive irregularities that it considers not material to the bid. PUBLIC INFORMATION: The responding vendor hereby acknowledges that all information relating to this bid and any resulting order (Including but not limited to fees, contracts, agreements and prices) are subject to these laws of the State of New Hampshire regarding public information. PERSONAL LIABILITY: The responding vendor agrees that in the preparation of this bid or the execution of any resulting contract or order, representatives of the State of New Hampshire shall incur no liability of any kind. PROOF OF COMPLIANCE. The responding vendor may be required to supply proof of compliance with proposal specifications. When requested, the responding vendor must immediately supply the Bureau of Purchase and Property with certified test results or certificates of compliance. Where none are available, the State may require independent laboratory testing. All costs for such testing certified test results or certificate of compliance shall be the responsibility of the responding vendor. FORM OF CONTRACT. The terms and conditions set forth in any additional Terms and Conditions by the Bureau of Purchase and Property are part of the bid and will apply to any contract awarded the responding vendor unless specific exceptions are taken and accepted and will prevail over any contrary provisions in Terms and Conditions submitted by the responding vendor. Revised: 06/29/20 LMR 3 CONTRACT TERMS AND CONDITIONS 1. The State of New Hampshire, acting through the Division of Procurement and Support Services, engages the firm or individual ("the Vendor") to perform the services and/or sale of goods, described in the attached State documents, if any, and the Vendor’s bid or quotation, both of which are incorporated herein by reference. 2. COMPLIANCE BY VENDOR WITH LAWS AND REGULATIONS. In connection with the performance of this agreement, the Vendor shall comply with all statutes, laws, regulations, and orders of federal, state, county or municipal authorities which shall impose any obligation or duty upon the Vendor, including, but not limited to civil rights and equal opportunity laws. 3. TERM. The contract, and all obligations of the parties thereunder, shall become effective on a specified date and shall be completed in their entirety prior to a specified date. Any work undertaken by the Vendor prior to the effective date shall be at his sole risk and, in the event that the contract shall not become effective, the State shall be under no obligation to reimburse the Vendor for any such work. 4. CONTRACT PRICE. The contract price, a payment schedule and a maximum limitation of price shall be as specified by the bid invitation and the Vendor’s bid. All payments shall be conditioned upon receipt, and approval by the State, of appropriate vouchers and upon satisfactory performance by the Vendor, as determined by the State. The payment by the State of the Contract Price shall constitute complete reimbursement to the Vendor for all expenses of any nature incurred by the Vendor in the performance by the Vendor and complete payment for the Services. The State shall have no other liability to the Vendor. 5. DELIVERY. If the vendor fails to furnish items and/or services in accordance with all requirements, including delivery, the state may re- purchase similar items from any other source without competitive bidding, and the original vendor may be liable to the state for any excess costs. If a vendor is unable to complete delivery by the date specified, he must contact the using agency. However, the agency is not required to accept a delay to the original delivery date. All deliveries are subject to inspection and receiving procedure rules as established by the State of New Hampshire. Deliveries are not considered accepted until compliance with these rules has been established. State personnel signatures on shipping documents shall signify only the receipt of shipments. All deliveries shall be FOB Destination. 6. INVOICING. All invoices must list Order Number, Unit and Extension Prices and discounts allowed. A separate invoice shall be submitted for each order. Unless otherwise noted on the invitation to bid or purchase order, payment will not be due until thirty (30) days after all services have been completed, or all items have been delivered, inspected and accepted or the invoice has been received at the agency business office, whichever is later. 7. PERSONNEL. 7.1. The Vendor shall disclose in writing the names of all owners (5% or more), directors, officers, employees, agents or subcontractors who are also officials or employees of the State of New Hampshire. Any change in this information shall be reported in writing within fifteen (15) days of their occurrence. 7.2. The person signing this agreement on behalf of the State, or his or her delegee ("Contracting Officer") shall be the State’s representative for purposes of this agreement. In the event of any dispute concerning the interpretation of this agreement, the Contracting Officer’s decision shall be final. 8. EVENT OF DEFAULT; REMEDIES. 8.1. Any one or more of the following acts or omissions of the Vendor shall constitute an event of default hereunder ("Events of Default"): 8.1.1. failure to deliver the goods or services satisfactorily or on schedule; or 8.1.2. failure to submit any report required hereunder; or 8.1.3. failure to perform any of the other covenants and conditions of this agreement. 8.2. Upon the occurrence of any Event of Default, the State may take any one, or more, or all, of the following actions: 8.2.1. give the Vendor a written notice specifying the Event of Default and requiring it to be remedied within, in the absence of a greater or lesser specification of time, thirty (30) days from the date of the notice; and if the Event of Default is not timely remedied, terminate this agreement, effective two (2) days after giving the Vendor notice of termination; and 8.2.2. give the Vendor a written notice specifying the Event of Default and suspending all payments to be made under this agreement and ordering that the portion of the Contract Price, which would otherwise accrue to the Vendor during the period from the date of such notice until such time as the State determines that the Vendor has cured the Event of Default, shall never be paid to the Vendor; and 8.2.3. set off against any other obligation the State may owe to the Vendor any damages the State suffers by reason of any Event of Default; and 8.2.4. treat the agreement as breached and pursue any of its remedies at law or in equity, or both. Revised: 06/29/20 LMR 4 9. WAIVER OF BREACH. No failure by the State to enforce any provisions hereof after any Event of Default shall be deemed a waiver of its rights with regard to that Event, or any subsequent Event. No express failure of any Event of Default shall be deemed a waiver of any provision hereof. No such failure or waiver shall be deemed a waiver of the right of the State to enforce each and all of the provisions hereof upon any further or other default on the part of the Vendor. 10. VENDOR’S RELATION TO THE STATE. In the performance of this agreement the Vendor is in all respects an independent contractor, and is neither an agent nor an employee of the State. Neither the Vendor nor any of its officers, employees, agents or members shall have authority to bind the State nor are they entitled to any of the benefits, workmen’s compensation or emoluments provided by the State to its employees. 11. ASSIGNMENT AND SUBCONTRACTS. The Vendor shall not assign, or otherwise transfer any interest in this agreement without the prior written consent of the State. No work required by this contract shall be subcontracted without the prior written consent of the State. 12. INDEMNIFICATION. The contractor shall defend, indemnify and hold harmless the State, its officers and employees, from and against any and all losses suffered by the State, its officers and employees, and any and all claims, liabilities or penalties asserted against the State, its officers and employees, by or on behalf of any person, on account of, based on, resulting from, arising out of (or which may be claimed to arise out of) the acts or omissions of the Vendor. Notwithstanding the foregoing, nothing herein contained shall be deemed to constitute a waiver of the sovereign immunity of the State, which immunity is hereby reserved to the State. This covenant shall survive the termination of this agreement. 12.1 PATENT PROTECTION. The seller agrees to indemnify and defend the State of New Hampshire from all claims and losses resulting from alleged and actual patent infringements and further agrees to hold the State of New Hampshire harmless from any liability arising under RSA 382-A:2-312(3). (Uniform Commercial Code). 13. TOXIC SUBSTANCES. In compliance with RSA 277-A Toxic Substances in the Workplace known as the Workers Right to Know Act, the vendor shall provide Safety Data Sheets (277-A:4 Safety Data Sheets) for all products covered by said law. 14. NOTICE. Any notice by a party hereto to the other party shall be deemed to have been duly delivered or given at the time of mailing by certified mail, postage prepaid, in a United States Post Office addressed to the parties at the addresses given below. 15. AMENDMENT. This agreement may be amended, waived or discharged only by an instrument in writing signed by the parties hereto. 16. CONSTRUCTION OF AGREEMENT AND TERMS. This agreement shall be construed in accordance with the laws of the State of New Hampshire, and is binding upon and inures to the benefit of the parties and their respective successors and assigns. 17. ADDITIONAL PROVISIONS. The additional provisions (if any) have been set forth as Exhibit "A" hereto. 18. ENTIRE AGREEMENT. This agreement, which may be executed in a number of counterparts, each of which shall be deemed an original, constitutes the entire agreement and understanding between the parties, and supersedes all prior agreements and understandings relating hereto. Revised: 06/29/20 LMR 5 BID INVITATION FOR: Custom Sexual Assault Evidence Kits (Supply & Deliver) PURPOSE: The purpose of this bid invitation is to establish a contract in the form of a purchase order, for supplying the State of New Hampshire with the item(s) indicated in the “Offer” section of this bid invitation, in accordance with the requirements of this bid invitation and any resulting order. This shall be a one-time order with delivery required to the location indicated in the F.O.B. section of this bid invitation. INSTRUCTIONS TO VENDOR: Read the entire bid invitation prior to filling it out. Complete the pricing information in the “Offer” section (detailed information on how to fill out the pricing information can be found in the “Offer” section); complete the “Vendor Contact Information” section; and finally, fill out, sign, and notarize page 1 of the bid invitation. BID SUBMITTAL: All bids shall be submitted on this form or an exact copy shall be typed or clearly printed in ink and shall be received on or before the date and time specified on page 1 of this bid under “Bid closing”. Interested parties may submit a bid to the State of New Hampshire Bureau of Purchase and Property by email to NH.Purchasing@DAS.NH.Gov. All bids shall be clearly marked with bid number, date due and purchasing agent’s name. IF YOU ARE EXPERIENCING DIFFICULTIES EMAILING YOUR BID OR YOU WISH TO VERIFY THAT YOUR BID RESPONSE HAS BEEN RECEIVED, PLEASE CALL (603) 271-2201. BID INQUIRIES: Any questions, clarifications, and/or requested changes shall be submitted by an individual authorized to commit their organization to the Terms and Conditions of this bid and shall be received in writing at the Bureau of Purchase and Property no later than 4:00 PM on the date listed in the timeline below. Questions shall not be submitted to anyone other than the Purchasing Agent or his/her representative. Bidders that submit questions verbally or in writing to any other State entity or State personnel shall be found in violation of this part and may be found non-compliant. Questions shall be submitted by E-mail to Loretta Razin at the following address: Loretta.M.Razin@DAS.NH.Gov Submissions shall clearly identify the bid Number, the Vendor’s name and address and the name of the person submitting the question. BID DUE DATE: All bid submissions shall be received at the Bureau of Purchase and Property no later than the date and time shown on the transmittal letter of this bid. Submissions received after the date and time specified shall be marked as “Late” and shall not be considered in the evaluation process. All bid submissions shall be treated as firm offers to remain valid for acceptance for a period of one hundred eighty (180) days from the bid due date. The transmittal of a vendor’s response or bid submission to any State agency or office other than the Department of Administrative Services (DAS), Bureau of Purchase and Property may be grounds for disqualification. ADDENDA: In the event it becomes necessary to add to or revise any part of this bid prior to the scheduled submittal date, the NH Bureau of Purchase and Property shall post on our web site any Addenda. Before your submission and periodically prior to the RFB closing, check the site for any addenda or other materials that may have been issued affecting the bid. The web site address is https://das.nh.gov/purchasing/purchasing.aspx TIMELINE: The timeline below is provided as a general guideline and is subject to change. Unless stated otherwise, consider the dates below a “no later than” date. 10/07/2020 Bid Solicitation distributed on or by 10/21/2020 Last day for questions, clarifications, and/or requested changes to bid 10/26/2020 11:00 AM (EST) Bid Closing mailto:NH.Purchasing@DAS.NH.Gov mailto:Loretta.M.Razin@DAS.NH.Gov https://das.nh.gov/purchasing/purchasing.aspx Revised: 06/29/20 LMR 6 GOVERNING TERMS AND CONDITIONS: A responding bid that has been completed and signed by your representative shall constitute your company’s acceptance of all State of New Hampshire terms and conditions and shall legally obligate your company to these terms and conditions. A signed response further signifies that from the time the bid is published (bid solicitation date and time) until a contract is awarded, no bidder shall offer or give, directly or indirectly, any gift, expense reimbursement, or honorarium, as defined by RSA 15-B, to any elected official, public official, public employee, constitutional official, or family member of any such official or employee who shall select, evaluate, or award the RFB. Furthermore, a signed response signifies that any terms and/or conditions that may be or have been submitted by the Vendor are specifically null and void and are not a part of this bid invitation or any awarded purchase order, even if said terms and/or conditions contain language to the contrary. CHAPTER ADM 600 PROCUREMENT AND PROPERTY RULES APPLY TO AND ARE MADE A PART HEREOF PUBLIC DISCLOSURE OF BID OR PROPOSAL SUBMISSIONS: Generally, the full contents of any bid or proposal (including all materials submitted in connection with it, such as attachments, exhibits, addenda, and vendor presentations) become public information upon completion of final contract or purchase order negotiations with the selected vendor. Certain information concerning bids or proposals, including but not limited to pricing or scoring, is generally available to the public even before this time, in accordance with the provisions of NH RSA 21-G: 37. To the extent consistent with applicable state and federal laws and regulations, as determined by the State, including, but not limited to, NH RSA Chapter 91-A (the “Right-to-Know” Law), the State shall, after final negotiations with the selected vendor are complete, attempt to maintain the confidentiality of portions of a bid or proposal that are clearly and properly marked by a bidder as confidential. Any and all information contained in or connected to a bid or proposal that a bidder considers confidential shall be clearly designated in the following manner: If the bidder considers any portion of a submission confidential, they shall provide a separate copy of the full and complete document, fully redacting those portions by blacking them out and shall note on the applicable page or pages of the document that the redacted portion or portions are “confidential.” Use of any other term or method, such as stating that a document or portion thereof is “proprietary”, “not for public use”, or “for client’s use only”, is not acceptable. In addition to providing an additional fully redacted copy of the bid submission to the person listed as the point of contact on Page one (1) of this document, the identified information considered to be confidential must be accompanied by a separate letter stating the rationale for each item designated as confidential. In other words, the letter must specifically state why and under what legal authority each redaction has been made. Submissions which do not conform to these instructions by failing to include a redacted copy (if required), by failing to include a letter specifying the rationale for each redaction, by failing to designate redactions in the manner required by these instructions, or by including redactions which are contrary to these instructions or operative law may be rejected by the State as not conforming to the requirements of the bid or proposal. The State will generally assume that a bid or proposal submitted without an additional redacted copy contains no information which the bidder deems confidential. Bids and proposals which contain no redactions, as well as redacted versions of submissions that have been accepted by the State, may be released to the public, including by means of posting on State web sites. The State shall have no obligation to maintain the confidentiality of any portion of a bid, proposal or related material, which is not marked in accordance with the foregoing provisions. It is specifically understood and agreed that the bidder waives any claim of confidentiality as to any portion of a response to this RFB or RFP that is not marked as indicated above, and that unmarked (or improperly marked) submissions may be disseminated to any person, without limitation. Marking an entire bid, proposal, attachment or full sections thereof confidential without taking into consideration the public’s right to know shall neither be accepted nor honored by the State. Notwithstanding any provision of this request for submission to the contrary, proposed pricing shall be subject to public disclosure REGARDLESS of whether or not marked as confidential. If a request is made to the State by any person or entity to view or receive copies of any portion of a proposal and if disclosure is not prohibited under NH RSA 21-G:37 or any other applicable law or regulation, bidders acknowledge and agree that the State may disclose any and all portions of the proposal or related materials Revised: 06/29/20 LMR 7 which is not marked as confidential. In the case of bids, proposals or related materials that contain portions marked confidential, the State shall assess what information it believes is subject to release; notify the bidder that the request has been made; indicate what, if any, portions of the proposal or related material shall not be released; and notify the bidder of the date it plans to release the materials. The State is not obligated to comply with a bidder’s designation regarding confidentiality. The State shall have no obligation to advise a bidder that an individual or entity is attempting to electronically access, or has been referred to, materials which have been made publicly available on the State’s web sites. By submitting a bid or proposal, the bidder agrees that unless it obtains and provides to the State, prior to the date specified in the notice described in the paragraph above, a court order valid and enforceable in the State of New Hampshire, at its sole expense, enjoining the release of the requested information, the State may release the information on the date specified in the notice without any liability to the bidder. Notwithstanding NH RSA 91-A:4, no information shall be available to the public, or to the members of the general court or its staff concerning specific responses to this bid invitation from the time this bid is published until the closing date for responses. VENDOR CERTIFICATIONS: All Vendors shall be duly registered as a vendor authorized to conduct business in the State of New Hampshire. • STATE OF NEW HAMPSHIRE VENDOR APPLICATION: Prior to bid award, Vendors shall have a completed Vendor Application Package on file with the NH Bureau of Purchase and Property. See the following website for information on obtaining and filing the required forms (no fee: https://DAS.NH.Gov/Purchasing VENDOR RESPONSIBILITY: The successful Vendor shall be solely responsible for meeting all terms and conditions specified in the bid, and any resulting contract. All State of New Hampshire bid invitations and addenda to these bid invitations are advertised on our website at: https://das.nh.gov/purchasing/vendorresources.aspx. It is a prospective Vendor’s responsibility to access our website to determine any bid invitation under which they wish to participate. It is also the Vendor(s)’s responsibility to access our website for any posted addendum. The website is updated several times per day; it is the responsibility of the prospective Vendor(s) to access the website frequently to ensure no bidding opportunity or addenda is overlooked. It is the prospective Vendor’s responsibility to forward a signed copy (if the form has a signature block) of any addenda to the Bureau of Purchase and Property with the bid response. In preparation of your bid response, you shall: • Complete the pricing information in the “Offer” section; and o You may include quote separately but the OFFER SECTION MUST be completed for complaint acceptance. • Complete all other required information on your offer (if applicable); and • Complete the “Vendor Contact Information” section; and • Complete the company information on the “Transmittal Letter” page, and sign the bid in the space provided on that page. The Transmittal Letter page shall be notarized to be an official submission. WARRANTY REQUIREMENTS: Successful Vendor shall be required to warranty all of the equipment/item awarded to Vendor for a period of not less than one (1) year or the manufacturer’s standard period of time, whichever is greater, from the date the items are received, inspected and accepted by the State of New Hampshire. The warranty shall cover 100% of all parts, shipping, labor, travel, lodging and expenses. BID PRICES: Bid prices shall be in US dollars and shall include delivery and all other costs required by this bid invitation. Special charges, surcharges, or fuel charges of any kind (by whatever name) may not be added on at any time. Any and all charges shall be built into your bid price at the time of the bid. Per Administrative Rule 606.01(e) “if there is a discrepancy between the unit price and the extension price in a response to an RFP, RFB or RFQ, the unit price shall be binding upon the vendor”. https://das.nh.gov/Purchasing https://das.nh.gov/purchasing/vendorresources.aspx Revised: 06/29/20 LMR 8 PAYMENT: Payment method (P-Card or ACH). Payments shall be made via ACH or Procurement Card (P-card = Credit Card) unless otherwise specified by the state of New Hampshire. Use the following link to enroll with the State Treasury for ACH payments: https://www.nh.gov/treasury/state-vendors/index.htm INVOICING: Invoices shall be submitted to the corresponding State agency after completion of work. AWARD: The award shall be made to the Vendor meeting the criteria established in this RFB and providing the lowest cost in total. The State reserves the right to reject any or all bids or any part thereof. If an award is made it shall be, in the form of a State of New Hampshire Purchase Order. Successful Vendor shall not be allowed to require any other type of order, nor shall the successful Vendor be allowed to require the filling out or signing of any other document by State of New Hampshire personnel. BID RESULTS: Bid results may be viewed when available, once the award has been made, on our web site only at: https://apps.das.nh.gov/bidscontracts/bids.aspx. For Vendors wishing to attend the bid closing: Names of the Vendors submitting responses and pricing shall be made public to the above website. There will be no public openings at this time. PRODUCT SAMPLES: If applicable, product sample must be the exact quality, brand and style being quoted in this bid. Vendors will be contacted during the evaluation process if sample is required - Do Not Submit Sample with Bid Response. All samples must be provided at no charge to the State of NH Bureau of Purchase and Property, and will not be returned. ARTWORK / IMPRINT INFORMATION: The Agency will approve the wording and layout as included with this RFB. If applicable, all art and reproduction materials are the property of the State of New Hampshire and shall be returned to the State at time of invoicing. The Agency will provide artwork in Jpeg or Adobe formatting. Vendor will be responsible for artwork if needed. All artwork costs must be built into bid pricing. Proof will be required and approved prior to final run. TERMINATION: The State of New Hampshire shall have the right to terminate the purchase contract at any time by giving the successful Vendor a thirty (30) day written notice. F.O.B.: The F.O.B. shall be destination to the following delivery point (included in the price bid), which means delivered to a state agency's receiving dock or other designated point as specified in this bid or subsequent purchase orders without additional charge: Department of Justice 33 Capitol Street Concord NH 03301 REQUISITION NO.: 206958 RETURNED GOODS: The successful Vendor shall resolve all order and invoice discrepancies within five business days from notification. Products returned due to quality issues, duplicate shipments, over-shipments, etc. shall be picked up by the successful Vendor within ten business days of notification with no restocking or freight charges, and shall be replaced with specified products or the agency shall be refunded/credited for the full purchase price. Unauthorized substitutions for any products are not allowed. Standard stock products ordered in error by the State of New Hampshire shall be returned for full credit within fifteen business days of receipt. Products shall be in re-saleable condition (original container, unused) and there shall be no restocking fee charged for these products. The using agency shall be responsible for any freight charges to return these items to the successful Vendor. https://www.nh.gov/treasury/state-vendors/index.htm https://apps.das.nh.gov/bidscontracts/bids.aspx Revised: 06/29/20 LMR 9 SPECIFICATION COMPLIANCE: Vendor's offer shall meet or exceed the required specifications as written. The State of New Hampshire shall be the sole determining factor of what meets or exceeds the required specifications. Unless otherwise specified by the Bureau of Purchase and Property in this bid invitation document, all products and equipment offered by the Vendor shall be new (and of the current model year, if applicable); shall not be used, rebuilt, refurbished; shall not have been used as demonstration products and equipment, and shall not have been placed anywhere for evaluation purposes. The manufacturer(s) and/or model(s) indicated in this bid are equivalent to the type and quality required. You may bid different make(s) and model(s); however, your offer must match or exceed the one(s) indicated and you must demonstrate to the satisfaction of the purchasing Agency that they meet or exceed the minimum standards. Items that don’t meet the minimum standards will not be accepted. Product literature and specifications may be enclosed. OFFER: Successful Vendor hereby offers to sell the required items to the State of New Hampshire at the following price: DELIVERED QTY UNIT DESCRIPTION UNIT COST EXT. COST 1000 Ea Sexual Assault Evidence Collection Kits in accordance with the requirements of this bid invitation and specifications as outlined in Attachment A. Kits should be printed with serial number sequence #9000-9999 and be packaged 10 per carton with carton marked with serial # sequence contained within. All envelopes must be peel and stick. A proof is required for approval before the final print run is completed. Indicative of Tri-Tech Forensics 5001 or Sirchie NH200 $ $ TOTAL $ Mfg./Make/Model: DELIVERY TIME: Successful Vendor agrees to complete delivery of items within 8 weeks of approval of proof or on or by January 15, 2021. No split deliveries. Prices offered shall include all products and delivery costs. Delivery must be in full, via straight truck with lift gate and pallet jack for inside delivery. Vendor must also return all artwork (electronically and hard copy) to NH Department of Justice upon completion of order. VENDOR CONTACT INFORMATION: Please provide contact information below for a person knowledgeable of and who can answer questions regarding, this bid response. ____________________________________ _______________________ __________________________ Contact Person Local Telephone Number Toll Free Telephone Number ____________________________________________ __________________________________________ E-mail Address Company Website __________________________________________ _______ __________________________________________________ Vendor Company Name Vendor Address Revised: 06/29/20 LMR 10 ATTACHMENTS: The following attachments are an integral part of this bid invitation: Attachment A: New Hampshire Sexual Assault Evidence Collection Kit 2020 Specifications Attachment B: Step 1 Attachment C: Step 2A and 2B Attachment D: Step 3A Attachment E: Step 3B Attachment F: Step 4 Outer Clothing Attachment G: Step 5 Underpants - Diapers Attachment H: Step 6-11 Swabs and Combings Attachment I: Step 12 Inventory Form Attachment J: Step 13 Female and Male Diagrams Attachment K: Step 14 Patient Information Form Attachment L: Step 15A-15C Forms for Patient Attachment M: Step 15E Financial Assistance Card Attachment N: Step 15D Bill of Rights Attachment O: Step 16 Postage paid Postcard Attachment P: Step 16A Billing Form Attachment Q: Box-Side 1 Long / Box-Side 2 Long / Box-Side 3 Short / Box-Side 4 Short / Box Top Attachment R: Nurse Instructions Note: To be considered, bid shall be signed and notarized on front cover sheet in the space provided. ------------ BID INVITATION FOR: Custom Sexual Assault Evidence Kits (Supply & Deliver) GENERAL CONDITIONS AND INSTRUCTIONS: BID INVITATION FOR: Custom Sexual Assault Evidence Kits (Supply & Deliver) BID INQUIRIES: BID DUE DATE: NEW HAMPSHIRE SEXUAL ASSAULT EVIDENCE COLLECTION KIT 2020 SPECIFICATIONS 1 ea. Kit Box: 10¼ in. long x 6¾ in. wide x 2¼ in. high, face printed as per sample. Each kit has serialized number affixed to the end of the box top. There will be no other numbers placed on that end of the kit box. Kit box to be pre-sealed via box top integrity seals (similar to a jigsaw puzzle box). Serial numbers to begin at 9000 and run consecutively through 9999. Kits will be packaged sequentially according to serial numbers and shipped in boxes with 10 kits per box. Boxes will be marked on the outside with the serial number seals of the kits inside. See example. 1 ea. Kit Instruction Sheet: Printed front and back on 8½” x 14” white stock. See example. 1 ea. Step 1 Authorization and Disclosure Form: Printed on 8½ in. x 11 in., 3-ply NCR type paper (minimum 20lb. paper weight). Box that says “Patient label” and bottom of form “Anonymous Cases:” should be blacked out on yellow and pink forms. - Bottom of form should indicate: “White - Retain for medical records, Yellow– Return to evidence kit, Pink – Law Enforcement if reported OR Kit if Anonymous”. See example. 1 ea. Step 2A Sexual Assault Medical/Forensic Report Form: Printed on 8½ in. x 11 in., 3 ply NCR type paper (minimum 20lb. paper weight). Bottom of form should indicate: “White – Retain for medical records, Yellow – Return to evidence kit. Pink – Law Enforcement if reported OR Kit if Anonymous”. Box that says “Patient label” should be blacked out on yellow and pink forms. See example. 1 ea. Step 2B Sexual Assault Medical/Forensic Report Form: Printed on 8½ in. x 11 in., 3 ply NCR type paper (minimum 20lb. paper weight). Bottom of form should indicate: “White – Retain for medical records, Yellow – Return to evidence kit. Pink – Law Enforcement if reported OR Kit if Anonymous”. Box that says “Patient label” should be blacked out on yellow and pink forms. Lines at bottom of page, under incident description, should be removed on yellow and pink forms. See example. 1 ea. Step 3A Toxicology Blood Samples Envelope: One white 6 in. x 9 in. peel and stick paper envelope with affixed labels. Envelope contains one 3 in. x 5½ in. bubble pack bag. See example for language on front of envelope. 1 TheraPakTM Absorbant Sheet (Fisher Scientific Cat. No 22- 130-040) to be included. 1 ea. Step 3B Toxicology Urine Sample Bags: - Bag #1 FisherbrandTM Tamper-Evident Closure Biohazard Bag (10in. x 6in.) with absorbant pad included (Cat. No. 01-813-16). - Bag #2 ULINE 2 Mil Reclosable Bag – blue (6 in. x 9 in.) (Model no. S-10847BLU). 3- 1/3 in. x 4 in. label on bag #2 with “ICE” printed on it. - Bag #3 SIRCHIE Integrity Evidence Bag (9in. x 12in.) (Cat. No. IEB9120). 2 ea. Step 4 Outer Clothing Bags: Plain paper box bottom bag with affixed label 18 ½ in. x 12 in. Affix label towards bottom of bag. See example. 1 ea. Step 5 Underpants/Diaper Bag: White paper box bottom bag with affixed label. 5 in. x 3 ¼ in. x 10 in. Affix label towards bottom of bag. See example. 1 ea. Step 6 Oral Swabs and Smear Envelope: One white 6 in. x 9 in. peel and stick paper envelope. Envelope contains (see example): - one printed swab box 6” x ½” (LynnPeavey Co. catalog no. 01313), - one package of 2 Puritan DNA-Free Cotton Tipped Applicator, Wood Handle, Puritan Medical Products (25-806 1WC FDNA) - one ringed microscope slide (Fisher Scientific 95042-274 or VWR 22-037-240) with “Oral” label affixed and one microscope slide holder. 1 ea. Step 7 DNA Sample/Buccal Swabs Envelope: One white 6 in. x 9 in. peel and stick paper envelope. Envelope contains (see example): - one printed swab box 6” x ½” (LynnPeavey Co. catalog no. 01313) - one package of 2 Puritan DNA-Free Cotton Tipped Applicator, Wood Handle, Puritan Medical Products (25-806 1WC FDNA) 1 ea. Step 8 Foreign Materials/Pubic Hair Combings Envelope: One white 6 in. x 9 in. peel and stick paper envelope. Envelope face incorporates front and rear body diagrams. Envelope contains (see example): - two printed swab boxes (LynnPeavey Co. catalog no. 01313) and - two packages of 2 Puritan DNA-Free Cotton Tipped Applicator, Wood Handle, Puritan Medical Products (25-806 1WC FDNA). - One wiper 18” x 13” (VWR catalog no. 82020-458 VWR® All-Purpose Disposable Cloth-like Wipes or equivalent) - one 5” black comb for Pubic Hair Combings, and two paper bindles. 1 ea. Step 9 Anal Swabs and Smear Envelope: One white 6 in. x 9 in. peel and stick paper envelope. Envelope contains (see example): - one printed swab box 6” x ½” (Lynn Peavey Co. catalog no. 01313) - one package of 2 Puritan DNA-Free Cotton Tipped Applicator, Wood Handle, Puritan Medical Products (25-806 1WC FDNA). - one ringed microscope slide (Fisher Scientific 95042-274 or VWR 22-037-240) with “Anal” label affixed and one microscope slide holder. 1 ea Step 10 External Genitalia/Penile Swabs Envelope: One white 6 in. x 9 in. peel and stick paper envelope. Envelope contains (see example): - one printed swab box (LynnPeavey Co. catalog no. 01313) - one package of 2 Puritan DNA-Free Cotton Tipped Applicator, Wood Handle, Puritan Medical Products (25-806 1WC FDNA). 1ea. Step 11 Vaginal/Cervical Swabs and Smear Envelope: One white 6 in. x 9 in. peel and stick paper envelope. Envelope contains (see example): - two printed 6” x ½” swab boxes (LynnPeavey Co. catalog no. 01313) - two packages of 2 Puritan DNA-Free Cotton Tipped Applicator, Wood Handle, Puritan Medical Products (25-806 1WC FDNA). - one ringed microscope slide (Fisher Scientific 95042-274 or VWR 22-037-240) with “Vaginal” label affixed and one microscope slide holder. 1 ea. Step 12 Sexual Assault Evidence Collection Kit Inventory Form: Printed on 8½ in. x 11 in. 1 ply white paper. Bottom of form should indicate: “Retain for medical records.” See example. 2 ea. Step 13 Medical/Forensic Examination Forms: Printed on 8 ½ in. x 14 in. Bottom of each form should indicate: “Retain for medical records”. One two-sided form for female exam, one two- sided form for the male exam. See examples. 1 ea. Step 14 Patient Information Form: Printed on 8 ½ in. x 14 in. 2-ply NCR type paper (minimum 20lb. paper weight). Bottom of form should indicate: “White – Retain for medical records, Yellow – Give to patient”. See example. 1 ea Step 15 Patient Discharge Documents Envelope: One manila 6 in. X 9 in. peel and stick envelope with a 3-1/3 in. x 4 in. sticker on it that says “Discharge Documents”. 1 ea. Step 15A HIVnPEP Patient Information Form: printed on 8 ½ in. x 11 in. yellow stock, double sided. Bottom of form should indicate “Give to patient if prescribed HIV nPEP”. See example. 1 ea. Step 15B Follow up Examination Voucher Form: Printed on 8 ½ x 11 in. yellow stock. Bottom of form should indicate “Give to patient.” See example. 1 ea. Step 15C List of Sexual Assault Crisis Centers: printed on 8 ½ in. x 11 in. yellow stock. Bottom of form should indicate “Give to every patient”. See example. 1 ea. Step 15D NH Crime Victim Bill of Rights: printed on 8 ½ in. x 11 in. yellow stock, double sided. Bottom of form should indicate “Give to every patient”. See example. 1 ea. Step 15E Financial Assistance for Victims Card: 6 in. x 3 ½ in. card stock, printed front and back, tri-folded to 3 ½ in. x 2 in. Yellow card stock. See example. 1 ea. Step 16 Postage paid Postcard: One 4 in. x 6 in. postcard addressed to the SANE Coordinator, NHCADSV, PO Box 353, Concord, NH, 03302-0353. Each postcard must have a forever stamp attached. See example. 1 ea. Step 16A Victims’ Compensation Billing form. Printed on 8 ½ in. x 11 in. paper, double sided. See example. 1 ea. Paper Ruler: Six inch long x one inch wide paper ruler with inches and centimeter measurements to be used when taking photographic evidence. 1 ea. Swab Drying Rack: Box 5 ½ in. long x 2 ½ in. wide x 2 in. high. Box should close on both ends and fold flat. (Equivalent to TriTech Forensics item #SADR-01) Six slots on top for insertion of swabs for drying labeled: - Oral Swabs - DNA/Buccal Swabs - Anal Swabs - Penile Swabs - Vaginal Swabs - Other Swabs 6 ea. Police Evidence Seals: Six 1¼ in. x 3½ in. red seals with black type for re-sealing kit following evidence collection. (Equivalent to TriTech Forensics item #ST-1A). 2 ea. Biohazard Stickers: Two 1 in. x 1 in. non-removable orange stickers with black type. 1 ea. Include a sheet of 40 non-removable # stickers in the kit that has the kit number on them. These stickers will match the kit number on the exterior of the boxes. 1 in. x ¾ in. White with black type. WHITE- Retain for Medical Records YELLOW-Return to Evidence Kit PINK-Law Enforcement if reported OR Kit if Anonymous STEP 1 AUTHORIZATION AND DISCLOSURE FORM[CL1] Kit Number: __________ Date of Birth: ____________________________________ Date of Examination: _______________________________ (Month/Day/Year) Call made to local crisis center for an advocate to support patient Yes No (This must be done with every case to support the patient and/or family) Hospital received permission to contact patient: By Telephone By Mail Permission Denied Indicate which of the following will be released: One sealed evidence collection kit containing evidence (including blood) Urine Sample for “Drug-Facilitated Sexual Assault” Test (sealed in biohazard bag OUTSIDE KIT) Evidence bags sealed outside of kit (examiner please indicate # ______ not including urine sample) Evidence Bags Article Description No. 1 ______________________________________ __________________________________________________ No. 2 ______________________________________ __________________________________________________ No. 3 ______________________________________ __________________________________________________ No. 4 ______________________________________ __________________________________________________ REPORTED CASES: Person authorizing release of information is (check one): Patient Patient’s Parent/Guardian Other __________________ Purpose of the use and/or disclosure: Mutually share information for health and safety. DISCLOSURE OF PROTECTED HEALTH INFORMATION/RECORD RELEASE I hereby authorize ________________________ (Health Care Facility) to collect and transfer my evidence collection kit, forms, and evidence to the below listed law enforcement agency. I also authorize law enforcement to deliver my evidence collection kit, forms and any other evidence to the NH State Police Forensic Laboratory for analysis. I further authorize the use/disclosure of my individually identifiable health information as described below (which may include information concerning treatment for drug/alcohol abuse, mental health and HIV status, if applicable). I understand that if the recipient authorized to receive the information is not a covered entity, (eg. insurance company or health care provider) the disclosed information may no longer be protected by federal and state privacy regulations. Do NOT sign below if completing an ANONYMOUS kit. Go to the bottom of the form. I hereby authorize ____________________________________________to release the following information covering treatment (Hospital/Record Holder) given to me on__________________________________ to ___________________________________________________. (Month/Day/Year) (Law Enforcement Agency/DCYF) Name of person authorizing release of information (please type or print): ________________________________________________ (Last) (First) (Middle) ___________________________________________________________ ________________________________________ Patient Signature Date ANONYMOUS CASES: DISCLOSURE OF PROTECTED HEALTH INFORMATION/RECORD RELEASE I hereby authorize ________________________ (Health Care Facility) to collect and transfer my evidence collection kit, forms and evidence bags to the above listed law enforcement agency. I also authorize law enforcement to deliver my evidence collection kit, forms and any other evidence to the NH State Police Forensic Laboratory. I understand that the law enforcement agency has not been given the right to view my record, or analyze the evidence, and will not be given that right except by my authority. PA T I E N T SI G N A T U R E DA T E _______ ____ _____ ____ _ ___________________________________________________________ ________________________________________ Witness/Examiner Signature Date Patient Label (top copy only) ANONYMOUS CASES: DISCLOSURE OF PROTECTED HEALTH INFORMATION/RECORD RELEASE Patient Signature Date _____________________ WHITE- Retain for Medical Records YELLOW – Return to Evidence kit PINK – Law Enforcement if reported OR Kit if anonymous STEP 2A SEXUAL ASSAULT MEDICAL/FORENSIC REPORT FORM Please complete in ALL cases regardless of patient’s age[CL1]. Kit Number: ___________ Date of Birth:__________ Age:_____ Gender Identity: ___________ Genetic Sex at Birth: __________ Preferred Pronouns: _______________________ Patient genitalia at exam (circle): vagina penis testicles Assault(s) Date: Assault(s) Time: ______________ Exam Date: _____________ Exam Time: _________________ Indicate by checking the appropriate box what the patient has done since the assault (if unsure, please state the reason why): Bathed/Showered Yes No Unsure Sponge Bath/Wiped Off Yes No Unsure Urinated/Defecated Yes No Unsure Brushed Teeth/ Mouthwash Yes No Unsure Changed Outer Clothing Yes No Unsure Changed Underpants Yes No Unsure Had Food/Drink Yes No Unsure Douched Yes No Unsure At the time of the assault was: A condom used by offender? Yes No Unsure Patient menstruating? Yes No Unsure Patient wearing a tampon or pad? Yes No Unsure Weapon used/threatened by offender? Yes No Unsure Patient strangled (choked)? Yes No Unsure • was patient able to breathe? Yes No • what mechanism was used to strangle (choke)? Describe___________________________________ Drug-facilitated assault suspected? Yes No if yes, suspected drug(s)? _________________ Voluntary drug/alcohol use? Yes No If yes, what was used and timeframe of use? __________________________________________________ At the time of the assault, were any of these symptoms experienced: Loss of consciousness? Yes No Unsure Impaired memory? Yes No Unsure Nausea/vomiting? Yes No Unsure Drowsiness/Sedation? Yes No Unsure Dizziness? Yes No Unsure Altered motor function? Yes No Unsure Hallucination/paranoia? Yes No Unsure Other? Yes No Describe If blood/urine sample is taken, is the patient taking any prescription drugs? Yes No If yes, which prescription drugs? _________________________________________ Any other witnesses to the incident? Yes No Unsure Date ______________________ Signature of Examiner ____________________________________ Patient Label (top copy only) WHITE- Retain for Medical Records YELLOW – Return to Evidence kit PINK – Law Enforcement if reported OR Kit if anonymous STEP 2B SEXUAL ASSAULT MEDICAL/FORENSIC REPORT FORM Please complete in ALL cases regardless of patient’s age[CL2]. Kit Number: ___________________________ Number of Offenders: Sex of Offender(s): Prior to exam: Was patient given any medication at the hospital prior to the exam? Yes No If yes, list medications: ________________________________________ At the time of the exam was: Patient menstruating? Yes No Unsure Patient wearing a tampon or pad? Yes No Unsure Within the past five days has the patient: Engaged in consensual sexual activity? Yes No If yes, on what date: ________ Was a condom used Yes No Was the consensual partner also the offender? Yes No Details of the assault obtained by patient (check all that apply): Patient was unable to provide history of assault at this time During the assault, were photos or video taken? Yes No Unknown Please describe: _____________________________________________________________________ Penetration performed by offender: penile/oral penile/genital penile/anal oral /anal oral/genital digital/genital digital/anal other (please describe) foreign object (please describe) other oral contact by offender (please describe) other oral contact by patient (please describe) ejaculation deposited on patient’s body (please identify location and swab area): ____________________________________________________________________________________ ____________________________________________________________________________________ Describe the details of the assault specifically related to the samples that have been collected:[P3] _________ Date ______________________ Signature of Examiner ___________________________________ Printed Name of Examiner ________________________________ Patient Label (top copy only) STEP 3A TOXICOLOGY BLOOD SAMPLES USE ONLY FOR SUSPECTED DRUG FACILITATED SEXUAL ASSAULT Kit #:______ Date Collected: ________ Time: _______ AM/PM Collected By: ______________________________________ • IF INGESTION WAS WITHIN 24 HOURS, COLLECT BLOOD SAMPLE. • IF INGESTION WAS OVER 24 HOURS, DO NOT COLLECT. Gray top tube(s) – 10ml minimum needed on adult patients. Note: If using 6ml tubes, include two. If using 4ml tubes, include three. (Use blood tube from hospital supply – if grey tubes are unavailable, use purple) STEP 3B TOXICOLOGY URINE SAMPLE USE ONLY FOR SUSPECTED DRUG FACILITATED SEXUAL ASSAULT DO NOT PLACE URINE SAMPLE INSIDE KIT Kit #:__________________________________ Date Collected: _____________ Time: _________ AM/PM Collected by:________________________________ • IF INGESTION WAS WITHIN 120 HOURS, COLLECT URINE. • IF INGESTION WAS OVER 120 HOURS, DO NOT COLLECT. up to 90ml urine (up to 120 hours) Urine 1. Collect urine in a sterile urine container (hospital supply) and seal in provided biohazard bag. 2. Place ice in second bag labeled ICE. Seal bag. 3. Place biohazard bag containing urine sample and “ICE” bag inside evidence bag and seal. Fill out labels accordingly. Freeze or place on ice immediately upon collection to preserve sample. Advise law enforcement to KEEP FROZEN. STEP 4 OUTER CLOTHING Kit #: ___________________ Date Collected: ___________________ Time: _______________ AM/PM Collected by: _______________________________________________________________________________ List Item(s) Enclosed: ______________________________________________________________________ CHAIN OF CUSTODY Received from: _______________________________________________________________________________ Date: _______________________________ Time: ________________AM/PM Accepted by: ________________________________________________________________________________ Received from: ______________________________________________________________________________ Date: _____________________________ Time: ___________________ AM/PM Accepted by: ________________________________________________________________________________ STEP 5 UNDERPANTS/DIAPER Kit #: _________________ Date collected: ___________________ Time: _____________AM/PM Collected by: ______________________ CHAIN OF CUSTODY Received from: _________________________________________________ Date: ________________________________Time: _______________ AM/PM Accepted by: ___________________________________________________ Received from:_________________________________________________ Date: ________________________________Time: _______________ AM/PM Accepted by: ___________________________________________________ STEP 6 ORAL SWABS AND SMEAR Kit #: _________________ Date collected: ___________________ Time: _____________AM/PM Collected by: __________________________________ • COLLECT WITHIN 24 HOURS STEP 7 DNA SAMPLE/BUCCAL SWABS Kit #: _________________ Date collected: ___________________ Time: _____________AM/PM Collected by: __________________________________ THIS SAMPLE MUST BE COLLECTED ON EVERY PATIENT • SWAB THE INNER ASPECTS OF BOTH CHEEKS WITH BOTH SWABS UNTIL MOISTENED STEP 8 FOREIGN MATERIALS/PUBIC HAIR COMBINGS Kit #: ______________ Date collected: _________________________ Time: _________________ AM/PM Collected by: ___________________________________________________ Collect any foreign material such as hair and fiber, etc. as well as any potential biological fluids left on body. Was pubic hair combing sample collected? (please circle) YES NO TIME _________ AM/PM Was foreign material/body swabbing sample collected? (please circle) YES NO TIME_________ AM/PM IDENTIFY LOCATION SAMPLE(S) COLLECTED FROM: Sample suspected to be: Saliva Semen Blood Hair Other: _______________ STEP 9 ANAL SWABS AND SMEAR Kit #: _________________ Date collected: ___________________ Time: _____________AM/PM Collected by: __________________________________ • COLLECT WITHIN 48 HOURS STEP 10 EXTERNAL GENITALIA / PENILE SWABS Kit #: _________________ Date collected: ___________________ Time: _____________AM/PM Collected by: __________________________________ • COLLECT WITHIN 72 HOURS OF THE ASSAULT • ALWAYS COLLECT SWABS IN PRE-PUBERTAL CASES STEP 11 VAGINAL/CERVICAL SWABS AND SMEAR Kit #: _________________ Date collected: ___________________ Time: _____________AM/PM Collected by: __________________________________ ADULT/ADOLESCENTS:  COLLECT WITHIN 120 HOURS OF ASSAULT  COLLECT 2 VAGINAL SWABS (collect simultaneously)  COLLECT 2 CERVICAL SWABS (collect simultaneously)  PREPARE 1 VAGINAL SMEAR PRE-PUBERTAL PATIENTS:  DO NOT COLLECT  COLLECT WITHIN 24 HOURS  SWAB THE INNER ASPECTS OF BOTH CHEEKS WITH BOTH SWABS UNTIL MOISTENED IDENTIFY LOCATION SAMPLE(S) COLLECTED FROM:  COLLECT WITHIN 48 HOURS Retain for Medical Records STEP 12 SEXUAL ASSAULT EVIDENCE COLLECTION KIT INVENTORY FORM Kit Number #: ____________________________ Check collected or not collected as appropriate Collected Not Collected Form completed Step 1: Authorization Always complete Step 2A: Medical/Forensic Report Form Always complete Step 2B: Medical/Forensic Report Form Always complete Step 3: Blood Toxicology Sample * Step 3: Urine Toxicology Sample * Step 4: Outer Clothing Number of Bags ______ Step 5: Underpants/Diaper Step 6: Oral Swabs and Smear Step 7: DNA Sample/ Buccal Swabs Step 8: Foreign Material Step 8: Pubic Hair Combings* Step 9: Anal Swabs and Smear Step 10: External Genitalia/Penile Swabs Step 11: Vaginal/Cervical Swabs and Vaginal Smear * Step 12: Sexual Assault Evidence Collection Kit Inventory Form Always complete Step 13: Medical/Forensic Examination Forms Always complete Step 14: Patient Information Form Always complete Step 15: Patient Forms a. HIVnPEP Patient Information Form Always when giving nPEP b. Follow Up Examination Voucher Form Give to PT c. Sexual Assault Crisis Center List Give to PT d. NH Crime Victims Bill of Rights Give to PT e. Financial Assistance for Victims Card Give to PT Step 16: Postcard (Provider MUST complete and mail) Always complete Step 16A: Forensic Sexual Assault Examination Billing Form Always complete Additional Evidence: please list: ____________________________________________________ Additional Evidence: please list: ____________________________________________________ *Any step with an asterisk is NOT routinely required with a pre-pubertal child. Date ______________________ Signature of Examiner ___________________________________ Patient Label: Retain for medical records STEP 13 (PAGE 1) MEDICAL/FORENSIC EXAMINATION FORM FEMALE BODY DIAGRAM Kit number #: _________________________ Please number findings on the body map with descriptors below. _____________________________ _______________ Date Signature of Examiner Number Description (e.g.,: Purple round bruise on right lateral wrist measuring .5cm x .5cm) Patient label: Retain for medical records STEP 13 (PAGE 2) MEDICAL/FORENSIC EXAMINATION FORM FEMALE GENITAL EXAM Kit Number #:______________________ FEMALE EXAMINATION: Tanner Stage Breast _____ Tanner Stage Pubic Hair _______ EXTERNAL GENITALIA: Labia Majora ________________________________ Clitoral hood & clitoris Labia Minora Fossa Navicularis ___________________________________________________________________________ Posterior fourchette/commissure Urethral meatus Hymen Indicate by checkmark visualization adjunct used: Foley catheter balloon technique (pubertal only) Toluidine Blue Dye Colposcopy Other OTHER ANO-GENITAL STRUCTURES: Vagina Cervix __________________ Adnexa Anus Rectum Perineum Were photographs/video taken by examiner? Yes No How many? What were photos taken of? Body Surface Genital _____________________________ ____________________________________________ Date Signature of Examiner Patient label: Retain for medical records STEP 13 (PAGE 1) MEDICAL/FORENSIC EXAMINATION FORM MALE BODY DIAGRAM Kit number #: _________________________ Please number findings on the body map with descriptors below. __________________________ ______________________________________________ Date Signature of Examiner Number Description (e.g., Purple round bruise on right lateral wrist measuring .5cm x .5cm) Patient label: Retain for medical records STEP 13 (PAGE 2) MEDICAL/FORENSIC EXAMINATION FORM MALE GENITAL DIAGRAM Kit number #: _________________________ MALE EXAMINATION: Tanner Stage Pubic Hair ____ Tanner stage Genitalia ________ PENIS: Glans Circumcised Uncircumcised Shaft Urethral Meatus Scrotum Testicles Perineum Anus Rectum Indicate by checkmark visualization adjunct used: Toluidine Blue Dye Other Were photographs taken by examiner? Yes No How Many What were photos taken of? Body Surface Genital __________________________ _____________________________________________ Date Signature of Examiner Patient label: Labia Majora ________________________________ PENIS: White Copy: Retain for medical records Yellow Copy: Give to patient STEP 14 PATIENT INFORMATION FORM Kit Number: _______________________________________________________ Hospital Name: _____________________________________________________ Hospital Telephone Number: __________________________________________ Date of Examination: ________________________________________________ (Month/Day/Year) With your consent, the following tests were conducted (check all that apply): Pregnancy Test Gonorrhea Chlamydia Trichomonas Hepatitis B HIV nPEP baseline labs Syphillis Hepatitis C Other ______________________ The following is a list of medications you were given. We recommend that you follow-up with your provider as directed to ensure that this treatment was effective. Medication Dose and Instructions _____________________________ _______________________________________________________ _____________________________ _______________________________________________________ _____________________________ _______________________________________________________ _____________________________ _______________________________________________________ _____________________________ _______________________________________________________ You chose not to be given medication that could prevent sexually transmitted infections. You chose not to be given medication that could prevent pregnancy, the time frame had passed when Emergency Pregnancy Prevention would have been considered effective, or is not applicable. You were given medicine called post-exposure prophylaxis (PEP) to reduce the risk of you becoming infected with HIV. You were given a copy of the HIV PROPHYLAXIS (HIV N PEP) PATIENT INFORMATION FORM (STEP 15A). For more information on HIV PEP medications and side effects call the National HIV N PEP Hotline at 1- 888-448-4911 and/or log onto the Centers for Disease Control website at www.cdc.gov. Samples were obtained to look for suspected drug facilitated sexual assault. The samples are not evaluated by the hospital laboratory. Information regarding the results should be obtained through the investigating law enforcement agency. If you are reporting ANONYMOUSLY, the samples will NOT be analyzed until you report the crime to law enforcement. You have chosen to have the evidence collection obtained ANONYMOUSLY. If you choose to report the crime to law enforcement, please call the _____________________ police department at this phone number __________________. The SERIAL NUMBER identifying your kit is ____________. You can report your sexual assault to law enforcement at any time. If you choose not to report the crime, the evidence will not be analyzed. Under the law, NH health care professionals are obligated to report all cases of suspected child abuse or elder/vulnerable adult abuse. Because of the circumstances that brought you in today, a report has been/will be made with the following agencies: NH Division of Children Youth and Families (1-800-894-5533) NH Bureau of Elderly & Adult Services (1-800-949-0470) Other ____________________________________________________ You have been given the following documentation: FOLLOW UP EXAMINATION VOUCHER FORM. SEXUAL ASSAULT CRISIS CENTER LIST for follow up support and confidential free services. NH CRIME VICTIM’S BILL OF RIGHTS. FINANCIAL ASSISTANCE FOR VICTIMS CARD. If you do not have medical insurance, the State of NH will pay for the cost of this evaluation. If you have insurance, please be sure all necessary information is forwarded to the hospital for billing purposes. Patient Signature ______________________________________________ Date: _______________________ Examiner Signature ____________________________________________ Time: _______________________ Patient label: (top copy only) STEP 15A HIV PROPHYLAXIS (HIVNPEP) PATIENT INFORMATION SHEET[ML1] You have been prescribed HIV post-exposure prophylaxis (PEP). These medicines can reduce the risk of becoming infected with HIV. The HIV nPEP medicines must be taken for a total of 28 days. Follow-up care from a nurse or doctor within 4-5 days is extremely important. There are several important things that you need to know when starting the medicines: Follow-up Care: Due to the potential side effects of this medication, you must be seen by a nurse or doctor within 4-5 days. Please call ______-________ tomorrow to schedule an appointment with __________________________________ (provider name) for your follow-up care regarding these HIV medications. Bring this form with you to this appointment. OR Your appointment has been scheduled for ____/_____/_____ at __________ AM/PM with ________________________________(provider name). Bring this form with you to this appointment. Medication Refills: You were given a ____ day supply of medicines, and you will need to get the remainder to complete the 28-day course of medicine. You should obtain the rest of the prescription from _______________________________________ Taking your Medicine: • These medications need to be taken as directed. • It is important that you do not miss any doses. Missing doses will decrease its effectiveness. • If you miss a dose, start taking again as soon as possible and make sure you allow the recommended amount of time between doses. • NEVER take more than the prescribed dose. • DO NOT STOP TAKING THE MEDICATION WITHOUT FIRST TALKING WITH YOUR DOCTOR OR NURSE. • CAUTION: Keep medication away from children and pets. Call your provider IMMEDIATELY if you experience rash, abdominal pain, fever, or severe nausea. GIVE TO PATIENT IF PRESCRIBED HIV nPEP IMPORTANT • THE HIV MEDICINES MUST BE TAKEN FOR A TOTAL OF 28 DAYS. • YOU MUST FOLLOW UP WITH A NURSE OR DOCTOR WITHIN 4 TO 5 DAYS OF STARTING THESE HIV MEDICATIONS You may experience other side effects from this medication. The most common side effects are: stomach upset, diarrhea and nausea, headache, muscle ache, insomnia, fatigue, weakness and/or tiredness, dizziness, lightheadedness, impaired concentration, vivid dreams and feeling “high”. If you experience any of these possible side effects, let your doctor or nurse know. They can help you manage these side effects. Side effects usually go away after a few days; tell your provider if they do not. NOTE: • Avoid alcohol • Take with food to decrease stomach upset Contact your doctor or nurse before starting any new medication. New medications may interact with many other prescriptions and over the counter medications, as well as street drugs. Frequently Asked Questions What if I want to stop these medications? Do not stop the medicines before you talk with your doctor or nurse. Take the medications as directed. They will not work as well if you miss a dose. What do I do if I have a problem with side effects from the medicines? Talk with your nurse or doctor if this happens. There are ways to manage side effects. Side effects usually get better after the first week. How should I store the medicines? Medicines should be stored as directed and kept out of the reach of children and pets. Should I be concerned if I take birth control pills? Some of these medicines may make birth control pills less effective. We recommend that if you are sexually active, you use latex condoms. This is especially important while you are taking these medicines. What if I take other drugs or medicines? Be sure to tell your doctor or nurse what other medicines or drugs you take. Other medicines including over-the-counter medicines can interact with PEP medicines. Also, street drugs can interact with these medicines. Will I need to have blood tests done? Yes, your doctor or nurse will tell you when you need to have blood tests done. It is important to get them done when recommended. GIVE TO PATIENT IF PRESCRIBED HIV nPEP ATTENTION: FOLLOW-UP MEDICAL PROVIDER If you are NOT an Infectious Disease provider, consult with an Infectious Disease provider in your area for the recommended HIVnPEP regimen, treatment and testing for this patient. STEP 15B[ML2] SEXUAL ASSAULT MEDICAL/ FORENSIC FOLLOW-UP EXAMINATION VOUCHER FORM New Hampshire Victims’ Compensation Program NH Department of Justice 33 Capitol Street Concord, NH 03301 Tel: 603-271-1284 Fax: 603-271-1255 Email: victimcomp@doj.nh.gov Billing Instructions for Health Care Providers: The State of New Hampshire is responsible for paying for the forensic/medical examination of victims of sexual assault (RSA 21- M:9-c), as well as one follow-up visit with the medical provider of her/his choice, paid at the fee for service Medicaid rate. The patient presenting this follow-up visit voucher, should not be required to pay any out of pocket costs for the follow-up examination you are performing, and should not be billed for any costs over the Medicaid rate. Please mail the original Voucher, along with an itemized bill, to the New Hampshire Victims’ Compensation Program at the above address. For the Medical Provider: (This voucher is not valid unless the following information is completed.) I, (Name of Patient) __________________________voluntarily authorize the disclosure of billing information, including name, date of birth., diagnosis and procedure codes. The information is to be disclosed by (Name of Provider) ________________________________ and is to be provided to the New Hampshire Victims’ Compensation Program at the NH Attorney General’s Office, 33 Capitol Street, Concord, New Hampshire 03301. The purpose of this disclosure is to verify patient information so that payment for treatment may be made. The information to be disclosed from my health record is only information related to the care provided to me on (Date) _____________ and I understand that my Protected Health Information (PHI) may be re-disclosed and therefore no longer protected under the Privacy Rule. I understand that the Attorney General’s Office will maintain the privacy of my PHI in accordance with RSA 21-M:8-c and will not release it without additional authorization. I further understand that I have the right to revoke this authorization in writing except to the extent that it has already been relied upon. The authorization is valid for one-year following the treatment date. Authorized by: ________________________________ Date: ____________________ (Patient Signature) Witness: _____________________________________ Date: ____________________ Relationship to Patient: ___________________________________________________ For the Follow-up Provider: (Please complete the following information so that we can pay you promptly.) Medical Provider: ____________________________________________________________ Federal Employer Identification Number: _________________________________________ Remittance Address: __________________________________________________________ GIVE TO PATIENT mailto:victimcomp@doj.nh.gov STEP 15C[sm3] NH DOMESTIC VIOLENCE and SEXUAL ASSAULT SUPPORT SERVICES N E W H A M P S H I R E C O A L I T I O N A G A I N S T D O M E S T I C A N D S E X U A L V I O L E N C E 603-224-8893 (Office) NH Domestic Violence Hotline: 1-866-644-3574 Statewide Sexual Assault Hotline: 1-800-277-5570 www.nhcadsv.org Teen Web Site: www.reachoutnh.org The New Hampshire Coalition is comprised of 13 programs throughout the state that provide services to survivors of sexual assault and domestic violence, stalking /or sexual harassment. You do not need to be in crisis to call. Services are free, confidential, and available to everyone regardless of age, race, religion, sexual preference, class, or physical ability. The services include: 24-hour crisis line, emergency shelter and transportation, legal advocacy in obtaining restraining orders against abusers, hospital and court accompaniment, information about and help in obtaining public assistance. RESPONSE to Sexual & Domestic Violence 54 Willow Street Berlin, NH 03570 1-866-662-4220 (crisis line) 603-752-5679 (Berlin office) 603-636-1747 (Groveton office) www.coosfamilyhealth.org/response Turning Points Network 11 School Street Claremont, NH 03743 1-800-639-3130 (crisis line) 603-543-0155 (fax Claremont office) 603-863-4053 (Newport office) www.turningpointsnetwork.org Crisis Center of Central New Hampshire (CCCNH) PO Box 1344 Concord, NH 03302-1344 1-866-841-6229 (crisis line) 603-225-7376 (office) www.cccnh.org Starting Point: Services for Victims of Domestic & Sexual Violence PO Box 1972 Conway, NH 03818 1-800-336-3795 (crisis line) 603-447-2494 (Conway office) 603-452-8014 (Southern Carroll County office) www.startingpointnh.org Sexual Harassment & Rape Prevention Program (SHARPP) 2 Pettee Brook Wolff House Durham, NH 03824 1-888-271-SAFE (7233) (crisis line) 603-862-3494 (office) www.unh.edu/sharpp Monadnock Center for Violence Prevention 12 Court Street Keene, NH 03431-3402 1-888-511-6287 (crisis line) 603-352-3782 (crisis line) 603-352-3782 (Keene office) 603-209-4015 (Peterborough) www.mcvprevention.org New Beginnings – Without Violence and Abuse PO Box 622 Laconia, NH 03247 1-866-841-6247 (crisis line) 603-528-6511 (office) www.newbeginningsnh.org WISE 38 Bank Street Lebanon, NH 03766 1-866-348-WISE (9473) (crisis line) 603-448-5525 (local crisis line) 603-448-5922 (office) www.wiseuv.org The Support Center at Burch House PO Box 965 Littleton, NH 03561 1-800-774-0544 (crisis line) 603-444-0624 (Littleton office) www.tccap.org/support_center.htm YWCA crisis Service 72 Concord Street Manchester, NH 03101 603-668-2299 (crisis line) 603-625-5785 (Manchester office) www.ywcanh.org Bridges: Domestic & Sexual Violence Support PO Box 217 Nashua, NH 03061-0217 603-883-3044 (crisis line) 603-889-0858 (Nashua office) www.bridgesnh.org Voices Against Violence PO Box 53 Plymouth, NH 03264 1-877-221-6176 (crisis line) 603-536-1659 (local crisis line) 603-536-5999 (public office) 603-536-3423 (shelter office) www.voicesagainstviolence.net HAVEN 20 International Drive, Suite 300 Portsmouth, NH 03801 603-994-SAFE (7233) (crisis line) 603-436-4107 (Portsmouth office) (Offices in Portsmouth, Rochester and Salem) www.havennh.org For Military Personnel NH National Guard Sexual Assault Response Coordinator (SARC): 603-856-6700 GIVE TO EVERY PATIENT http://www.nhcadsv.org/ http://www.reachoutnh.org/ http://www.coosfamilyhealth.org/response http://www.turningpointsnetwork.org/ http://www.cccnh.org/ http://www.startingpointnh.org/ http://www.unh.edu/sharpp http://www.mcvprevention.org/ http://www.newbeginningsnh.org/ http://www.wiseuv.org/ http://www.tccap.org/support_center.htm http://www.bridgesnh.org/ http://www.voicesagainstviolence.net/ http://www.havennh.org/ Step 15A HIV PROPHYLAXIS (HIVnPEP) New Hampshire Coalition Against Domestic and Sexual Violence VICTIMS OF SEXUAL ASSAULT SHOULD NOT BE BILLED FOR THE FOLLOWING SERVICES:   ● The Medical/Forensic Examination following the assault, including the collection of evidence in a sexual assault kit. Even if you have an evidence collection kit performed, it is your decision whether or not to report the crime, unless you are a minor. Collecting evidence as soon as possible after the assault is crucial to possible prosecution of the perpetrator. ● One Follow-up Examination with the medical provider of your choice. ● Payment of HIV Prevention Medications if determined to be appropriate by the medical provider. ● Testing for “Date-Rape” drugs. If you suspect you were drugged prior to being assaulted, get tested immediately, while the drug is still in your system. ADDITIONAL EXPENSES THAT MAY BE COVERED INCLUDE:  Medications, such as those to prevent pregnancy, Hepatitis B, and other sexually transmitted infections. Clothing and Bedding that are taken as evidence by law enforcement. Lost Wages due to inability to work as a result of the physical and psychological aftermath of the assault. Mental Health Counseling with a licensed practitioner.   To receive compensation for additional crime-related expenses, you must file a claim with the New Hampshire Victims’ Compensation Program. You must report the crime to local law enforcement to be eligible for this program OR Report to the hospital within 10 days of the assault and comply with the evidence collection to be eligible for this program. For more information call 1-800-300-4500 Or email victimcomp@doj.nh.gov   To apply online, go to https://ccvcnh.org The aftermath of sexual assault can be a confusing and overwhelming time. Sexual assault victims may be eligible to receive financial compensation for a variety of crime related expenses and/or lost wages and support. You may be eligible for compensation for some of the expenses listed on the back of this card. Help for Victims of Sexual Assault Your local Crisis Center provides information, support and referrals 24 hours a day, and can provide short term emergency funds for expenses such as having your locks changed, and replacing emergency items that may have been lost or damaged as a result of the assault. These services are free and confidential. To contact the Crisis Center nearest you call the Statewide Sexual Assault Hotline at 1-800-277-5570 NEW HAMPSHIRE CRIME VICTIM BILL OF RIGHTS Victims of felony crimes committed by an adult offender are entitled to the following rights under NH RSA 21-M:8-k: • The right to be treated with fairness and respect for the victim's safety, dignity, and privacy throughout the criminal justice process. • The right to be informed about the criminal justice process and how it progresses. • The right to be free from intimidation and to be reasonably protected from the accused throughout the criminal justice process, including the right to relocate for the victim's safety. • The right to reasonable and timely notice of all court proceedings, including post- conviction proceedings, and administrative proceedings including parole and probation. • The right on the same basis as the accused to attend trial and all other court proceedings, including post-conviction proceedings. • The right to confer with the prosecution and to be consulted about the disposition of the case, including plea bargaining. • The right to have inconveniences associated with participation in the criminal justice process minimized. • The right to be notified if presence in court is not required. • The right to be informed about available resources, financial assistance, and social services. • The right to full and timely restitution, as granted under RSA 651:62-67 or any other applicable state law, or victim's compensation, under RSA 21-M:8-h or any other applicable state law, for their losses. • The right to be provided a secure, but not necessarily separate, waiting area during court proceedings. • The right to be advised of case progress and final disposition. • The right of confidentiality of the victim's address, place of employment, and other personal information. • The right to the prompt return of property when no longer needed as evidence. • The right to have input in the probation presentence report impact statement. • The right to appear and be heard at any disposition and any proceeding involving the release, plea, sentencing, or parole of the accused, including the right to be notified of, to attend, and to make a written or oral impact statement at the sentence review hearings and sentence reduction hearings. No victim shall be subject to questioning by counsel when being heard. • The right to be notified of an appeal, an explanation of the appeal process, the time, place and result of the appeal, and the right to attend the appeal hearing. • The right to be notified of, to attend, and to make a written or oral victim impact statement at the sentence review hearings and sentence reduction hearings. No victim shall be subject to questioning by counsel when giving an impact statement. • The right to be notified of any change of status such as prison release, permanent interstate transfer, or escape, and the date of the parole board hearing, when requested by the victim. Kit # (place sticker here) STEP 15D • The right to address or submit a written statement for consideration by the parole board on the defendant's release and to be notified of the decision of the board, when requested by the victim. • The right to all federal and state constitutional rights guaranteed to all victims of crime on an equal basis, and notwithstanding the provisions of any laws on capital punishment, the right not to be discriminated against or have their rights as a victim denied, diminished, expanded, or enhanced on the basis of the victim's support for, opposition to, or neutrality on the death penalty. • The right to access to restorative justice programs, including victim-initiated victim- offender dialogue programs offered through the department of corrections. • The right to be informed of the filing of a petition for post-conviction DNA testing under RSA 651-D. • The right to have the prosecuting attorney notify the victim's employer, if requested by the victim, of the necessity of the victim's cooperation and testimony in a court proceeding that may necessitate the absence of the victim from work for good cause. In addition to the rights of a crime victim provided above, a sexual assault survivor shall have the following rights: • The right not to be prevented from, or charged for, receiving a medical examination • The right to: o Have a sexual assault evidence collection kit or its probative contents preserved, without charge, for the duration of the maximum applicable statute of limitations or 20 years, whichever is shorter; o Be informed of any result of a sexual assault evidence collection kit, including a DNA profile match, toxicology report, or other information collected as part of a medical forensic examination, if such disclosure would not impede or compromise an ongoing investigation; and o Be informed in writing of policies governing the collection and preservation of a sexual assault evidence collection kit. • The right, if the state intends to destroy or dispose of a sexual assault evidence collection kit or its probative contents before the expiration date of the maximum applicable statute of limitations, to: o Upon written request, receive written notification from the prosecutor or appropriate state official with custody not later than 60 days before the date of the intended destruction or disposal; and o Upon written request, be granted further preservation of the kit or its probative contents. • The right to be informed of the rights under this section. GIVE TO EVERY PATIENT NEW HAMPSHIRE CRIME VICTIM BILL OF RIGHTS [MS1] NHCADSV PO BOX 353 CONCORD, NH 03302 Kit Serial #: ____________________________ Name of Examiner:_____________________ SANE __yes __ no Hospital: _____________________ Date Collected: ___/____/____  Reported  Anonymous  Minor  Adult Police Department accepting Kit for transfer to Crime Lab: ________________________________________________________ (City and State) IN ALL CASES, PLEASE FILL OUT AND MAIL UPON COMPLETION OF THE EVIDENCE COLLECTION KIT. STEP 16A STATE OF NEW HAMPSHIRE VICTIMS’ COMPENSATION FORENSIC SEXUAL ASSAULT EXAMINATION BILLING FORM (name of patient or “anonymous”) has been informed that the NH Victims’ Compensation Program can provide payment for the examination, collection of evidence, and treatment related to this sexual assault visit; including HIV Post Exposure Prophylaxis, if necessary. It is the intent of this form to allow the patient to make an informed decision concerning the method of payment she/he chooses. Please choose an option: • _Patient does not have insurance that would cover this treatment. • Patient does have insurance or Medicaid which will be billed. Patient will not be charged for any co-payments or deductibles associated with this treatment. • Patient does have insurance that would cover this treatment but does not want insurance carrier billed. _ This section must be completed by the SANE provider or treating physician: Forensic Sexual Assault Examination Kit # _ Patient’s Account #_ _ Patient’s Date of Birth (REQUIRED) RX (for HIV nPEP medications ONLY):___________________ Were HIV nPEP medications dispensed in ED? Yes No # of days HIV nPEP medications dispensed: _______ (circle one) The City/State/County where assault occurred: _ (NH Victims’ Compensation Program can only provide payment for assaults occurring in NH. If assault occurred in another state, please contact the Victims’ Compensation Program of that state.) HIV POST EXPOSURE PROPHYLAXIS PRESCRIPTION MEDICATIONS WILL BE PAID TO THE HOSPITAL/FACILITY AT MEDICAID RATE BY THE NH VICTIMS’ COMPENSATION PROGRAM. _ _ SANE or Attending Physician (please print) Signature of SANE or Attending Physician Telephone _ _ _ Name of Facility Name of Billing Contact Person Telephone Date of Service Please use the universal UB invoice with back up documentation, including the services provided, medical record and appropriate medical coding. This form must be attached to UB invoice. Failure to provide all requested information will result in denial of payment. When completed, please mail these documents to: New Hampshire Victims’ Compensation Program Office of the Attorney General 33 Capitol Street Concord, NH 033301 Telephone: 603-271-1284 victimcomp@doj.nh.gov Note to provider: Be sure that your billing department has a copy of this completed Billing Form and Instructions. 08/2020 Hospital Label mailto:victimcomp@doj.nh.gov STATE OF NEW HAMPSHIRE Forensic Sexual Assault Examination Billing Form INSTRUCTIONS 1. The patient has the right to remain anonymous or provide their name when submitting a forensic sexual assault exam. Please list anonymous OR the patient’s name. 2. Payment options: a. Option 1: If this option is selected the hospital will be reimbursed by the NH Victims’ Compensation Program at the Fee for Service Medicaid rate for evidence collection. b. Option 2: If this option is selected, the patient cannot be billed for co-payment or deductibles. c. Option 3: If this option is chosen, neither the patient nor the insurance provider is billed. The hospital will be reimbursed by the NH Victims’ Compensation Program at the Fee for Service Medicaid rate for evidence collection 3. A forensic sexual assault examination kit number and patient’s date of birth must be provided in order for the NH Victims’ Compensation Program to consider payment at the Fee for Service Medicaid rate. 4. An itemized billing statement (universal UB form), with appropriate medical codes, must be submitted with the billing form for payment consideration. Please also provide a copy of the medical record for this date of service. Failure to provide a billing statement, medical record and payment form will delay the processing of this claim. 5. Complete all other sections of this form as indicated. Incomplete forms will be returned to the hospital as unable to process. 6. Once completed, MAIL/FAX this form and required billing documentation to: The New Hampshire Victims’ Compensation Program 33 Capitol Street Concord, NH 03301 603-271-1284 victimcomp@doj.nh.gov mailto:victimcomp@doj.nh.gov STATE OF NEW HAMPSHIRE VICTIMS’ COMPENSATION FORENSIC SEXUAL ASSAULT EXAMINATION Please choose an option: This section must be completed by the SANE provider or treating physician: STATE OF NEW HAMPSHIRE 2. Payment options: The New Hampshire Victims’ Compensation Program SEXUAL ASSAULT EVIDENCE COLLECTION KIT EXPIRATION DATE NOTATION: THE PRODUCT EXPIRATION DATE APPLIES TO SPECIFIC COMPONENTS ENCLOSED. IF THE EXPIRATION DATE HAS PASSED, PLEASE SEE ENCLOSED FDA INSERT FOR PRODUCT UPDATING INFORMATION. REORDER NUMBER: EXPIRATION DATE: LOT NUMBER: EVIDENCE SEAL HERE EXPIRATION DATE NOTATION: REORDER NUMBER: EXPIRATION DATE: LOT NUMBER: SEXUAL ASSAULT EVIDENCE COLLECTION KIT EVIDENCE SEAL HERE SEXUAL ASSAULT EVIDENCE COLLECTION KIT MANUFACTURED BY COMPANY NAME ADDRESS Corresponding serial number Bar Code here Kit serial number here SEXUAL ASSAULT EVIDENCE COLLECTION KIT MANUFACTURED BY COMPANY NAME ADDRESS STATE OF NEW HAMPSHIRE SEXUAL ASSASULT EVIDENCE COLLECTION KIT JURISDICTION OF ASSAULT (TOWN, STATE): _________________________________ PATIENT’S NAME (print): _____________________________________ D.O.B: _____________ (Replace with kit serial number for anonymous reports) HOSPITAL: _______________________________________ DATE OF EXAM: ____________ EXAMINER NAME (print): __________________________________________________________ EXAMINER SIGNATURE: __________________________________________________________ CHAIN OF CUSTODY I certify that I have received the following items (check those which apply): One sealed evidence kit Sealed clothing bag (s) Number of bags _______ Urine Sample (on ice) Other __________________________________________ DATE: _________________ TIME: ___________ AM/PM RECEIVED FROM: _________________________________________________________________________ ACCEPTED BY: ____________________________________________________________________________ DATE: _________________ TIME: ___________ AM/PM RECEIVED FROM: _________________________________________________________________________ ACCEPTED BY: ____________________________________________________________________________ DATE: _________________ TIME: ___________ AM/PM RECEIVED FROM: _________________________________________________________________________ ACCEPTED BY: ____________________________________________________________________________ ALWAYS DELIVER THE KIT TO THE CRIME LABORATORY WITHOUT DELAY Kit contains liquid blood sample, kit MUST BE refrigerated: yes no Urine collected: yes no MUST ALWAYS FREEZE URINE For questions about collection procedures, please see the State of New Hampshire Office of the Attorney General Sexual Assault: An Acute Care Protocol for Medical/Forensic Evaluation http://www.doj.nh.gov/criminal/victim-assistance/documents/acute-care-protocol.pdf For other information call the State Police Forensic Laboratory (603) 223-3854 TO REORDER KITS CALL: (603) 271-6817 Kits are provided free of charge by The State of New Hampshire Department Of Justice AFFIX BIOHAZARD STICKER HERE http://www.doj.nh.gov/criminal/victim-assistance/documents/acute-care-protocol.pdf NEW HAMPSHIRE SEXUAL ASSAULT EVIDENCE COLLECTION KIT INSTRUCTIONS USE POWDER FREE GLOVES CHANGE GLOVES BETWEEN EVERY EVIDE