IMPORTANT
All exams MUST be submitted on state exam forms,
NO EXCEPTIONS.
Exams submitted on facility forms will not be reviewed by the Commission and will be
returned to you to be rewritten onto state exam forms. This is the only way for the
Commission to evaluate all applicants fairly.
Common mistakes and how to avoid them:
Mistake # 1: Sending in exams on facility-specific forms.
Instead: Send them in on the latest state exam form.
Mistake # 2: Sending in an exam with missing pages.
Instead: Double check that you are sending in the state exam form, pages 1-15. In
particular, make sure to include page 15, HIV Risk Assessment/Medications/Referrals.
Mistake #3: Blanks and missing information.
Instead: Include medication names and dosages. Explain “unknown” or “attempted”
answers. Note when patient declines an option.
Mistake #4: Sending in extra pages.
Instead: Send in the state exam form, pages 1-15. Other medical records or extra exams
will be shredded.
Mistake #5: Not de-identifying your charts.
Instead: Make sure ALL identifying information is blacked out or removed. Refer to the
instructions if you’re unsure what information this includes.
If the Commission feels they cannot fully evaluate your competency for the reasons
above or any other reason, you will be asked to send in additional information during
the next application cycle.
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Oregon SANE/SAE Certification Application
First Name
MI
Last Name
Address
City, State, Zip Code
Phone #
E-mail Address
License Number
County of Employment
Employer
Medical Director
Work Address
Work City, State, Zip Code
Work Phone #
Please submit along with this completed application packet:

Copy of certificate from 40-hour SANE/SAE Training (check appropriate box below)
□ Oregon didactic course
□ IAFN didactic course
□ Other didactic course

Application fee: $100, non-refundable. Please send check or money order, payable to the
Oregon SANE Certification Commission.

Please do NOT use staples in your application. Thank you!
Active Practice Verification:
By signing below, I affirm that I hold a current unrestricted License in Oregon and that I am actively
practicing in a clinical practice with an average of 16+ hours of direct patient contact per month.
Applicant Signature
Date
Mail all materials to:
Oregon SANE/SAE Certification Commission
3625 River Road North, Suite 275
Keizer, OR 97303
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Non-Clinical Requirements Validation Form
Applicant Name
Activity
Date
Law Enforcement Agency
□
Ride Along
and/or
□
Case Review
Criminal Court Observation
Type of Case:
Judge:
District Attorney’s Office Observation
County:
DA:
Advocacy
□
County Victim Assistance Program
and/or
□
Non-Profit Victim Assistance Program
Crime Lab Tour and Orientation
Location:
Recommended/Optional
□
□
SART Meeting
Other:
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Signature
Title and Agency
Contact Phone Number
Speculum Exam Validation and Evaluation Checklist
(Applicant must submit either this form or Speculum Exam Exemption Waiver Request Form)
Applicant Name
Please evaluate each skill:
1 = Demonstrates competence
Skill
1
Introduces self and role
Explains procedure
Confirms consent for exam
Offers patient chance to empty bladder
(collects urine when appropriate)
Wears gloves
Selects appropriately sized speculum, lubricate
with water-based lubricant or water
Maintains patient dignity, drape appropriately
Identifies and inspects labia majora, labia
minora, general appearance, injury assessment
Avoids startling patients: explains actions,
instructs patient to relax, touches appropriately
Retracts labia majora, identifies and inspects
clitoris, urethral meatus, anterior vaginal wall,
hymen, fossa navicularis, posterior fourchette,
perineum
Inserts speculum
Rotates and opens speculum, assures proper
placement
Visualizes cervix (fornix, anterior cervix, cervical
os), describes findings
Identifies techniques for collecting swabs
Removes speculum
Removes gloves, washes hands
Documents observations
Observes clean technique throughout procedure
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2
3
2 = Needs more practice
4
5
6
7
8
9
10
Evaluators: Please personally observe and evaluate each speculum exam individually.
Evaluator Name, Title, Medical Facility
Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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Comments
Speculum Exam Exemption Waiver Request Form
(Applicant must submit either this form or Speculum Exam Validation and Evaluation Form)
If you are a health care professional who conducts speculum exams as part of your routine medical
practice, please fill out this form to request a waiver exempting you from the ten observed speculum
exams required for certification.
Full Name
Title
E-mail Address
Phone #
Medical Facility
Approximately how many speculum exams do you conduct in a year? (Answer must be >10.)
By signing below, I am verifying that I conduct more than ten speculum exams in a year, as part of my
routine medical practice.
Signature of Applicant
Date
By signing below, I am verifying that the above applicant conducts more than ten speculum exams in
a year as part of their routine medical practice, and that I have personally observed and can attest to
their competency.
Signature of Supervisor
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Date
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Sexual Assault Medical Forensic Exam
Competency Checklist
Observing exam: The recommendation of the Oregon SANE Certification Commission is that the
applicant should first observe a live or mock exam by an experienced SANE. A reflection is required for
this “Observing” exam, but no competency checklist or chart should be submitted.
Performed exams: The second, third, and fourth exams should be a combination of “Being Observed”
by an experienced SANE and “Independent.” Guidelines:
● At least one exam must be completed as “Being Observed” and at least one exam must be
completed as “Independent.”
● Two of these exams may be completed as mock exams. The Commission strongly recommends that
only one of them be a mock exam to reduce the chance of being asked for additional information.
Along with this form, please submit your de-identified charts on the state Oregon Sexual Assault
Medical Forensic Exam Form and exam critiques and self-reflections for all three performed exams.
Please check all that apply for your three performed exams.
Exam One:
Exam Two:
Exam Three:
Date:
Date:
Date:
□ Being Observed
□ Being Observed
□ Being Observed
□ Independent
□ Independent
□ Independent
□ Mock
□ Mock
□ Mock
Applicant Name
Please evaluate each skill:
1 = Demonstrates competence
2 = Needs more practice
Skill
1
Patient medically cleared before exam.
Set up room, gather supplies: SAFE Kit, forms, speculum, blankets, swab dryer,
water, alternative light source.
Introduce self to patient, explain that an advocate has been called.
Available options explained:
□ Medical assessment with evidence collection, <84 hrs post-assault: Includes
sexual assault evidence kit, urine pregnancy test, STI prophylaxis, emergency
contraception, referrals, follow-up care.
□ Medical assessment without evidence collection, any time post-assault: May
include urine pregnancy test, STI prophylaxis, emergency contraception, referrals,
follow-up care.
Options for reporting and non-reporting evidence collection explained.
Respect demonstrated for patient choices and autonomy.
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2
3
Explains and obtains Exam Consent, Medical Release, and SAVE Form.
Must receive a 1 in this category for exam to count toward certification.
Mandatory report made if applicable.
Medical screening discussed.
Presence of advocate and/or support person offered.
Health history obtained as necessary while protecting patient privacy.
History of assault obtained.
Collection, packing, and processing of urine verbalized if applicable.
Option/process to obtain clothing for evidence explained.
Has patient undress on sheet of white exam paper or sheet.
Places each item of clothing in separate bag to be labeled.
Swab dryer disinfected with bleach prior to use and used appropriately.
Head to toe physical exam and evidence collection completed per history.
Detailed ano-genital exam and evidence collection completed per history.
Option for photography explained to patient if available. Process explained.
SAFE kit processed properly during exam: drying, packaging, labeling, etc.
STI prophylaxis and emergency contraception offered where indicated.
Shower and change of clothes offered if available.
Discharge instructions provided, including: meds given, follow-up care, referrals,
injury/wound care. Safety plan developed with advocate.
Process for securing each bag with patient label or kit number (if anonymous),
date/time collected, and SANE signature verbalized.
Chain of evidence process described.
Debrief completed with patient.
Documentation completed: SA form, consents, bodygrams, photos.
Fill out Log Book (kept in locked area) with date, MRN, patient name, exam start and
finish times, and SANE name.
Swab dryer disinfected with bleach solution, exam area thoroughly cleaned.
Applicant Signature:
Preceptor Name (“Being Observed” exam):
Preceptor Signature (“Being Observed” exam):
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Sexual Assault Medical Forensic Exam
Critique and Self-Reflection Instructions
Please attach a critique and self-reflection for each exam, observing and performed. Guidelines are
below for each type of exam. Be clear and thorough, with specific examples. Include a reflection on any
bias, emotional reactions, and thoughts about the SANE process.
Observing:
● Quality and elements of the exam
● Flow of the exam
● Three parts that went well
● Three parts that could be improved
Being Observed:
● Quality and elements of the exam
● Feedback from your preceptor regarding:
○ Flow of exam
○ Three parts that went well
○ Three parts that could be improved
Independent:
● Quality and elements of the exam
● Identify and list what made you uncomfortable and why
● Describe your organization, flow of the examination, and rationale
● What went well and why
● Opportunities for improvement
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