DOD Instruction 6310.09 Health Care Management for Patients

DOD INSTRUCTION 6310.09

EALTH CARE MANAGEMENT FOR PATIENTS ASSOCIATED

WITH A SEXUAL ASSAULT

Originating Component: Office of the Under Secretary of Defense for Personnel and

Readiness

Effective:

Releasability:

Approved by:

May 7, 2019

Cleared for public release. Available on the Directives Division

Website at https://www.esd.whs.mil/DD/.

James N. Stewart, Assistant Secretary of Defense for Manpower

and Reserve Affairs, Performing the Duties of the Under Secretary

of Defense for Personnel and Readiness

Purpose: In accordance with the authority in DoD Directive (DoDD) 5124.02, DoD Instruction

(DoDI) 6400.01, and DoDI 6495.02, this issuance:

• Establishes policy and assigns responsibilities for developing and publishing procedural

guidance for providing health care in the Military Health System.

• Prescribes procedures to ensure comprehensive standards for providing health care in the

Military Health System for patients who, during the course of health care, present with a

disclosure of sexual assault, or disclose they have committed or are suspected to have committed

a sexual assault.

• Implements:

o Sections 1723 and 1725 of Public Law 113-66.

o Section 538 of Public Law 113-291.

o Sections 538 and 539 Public Law 114-92.

DoDI 6310.09, May 7, 2019

TABLE OF CONTENT 2

TABLE OF CONTENTS

SECTION 1: GENERAL ISSUANCE INFORMATION .............................................................................. 3

1.1. Applicability. .................................................................................................................... 3

1.2. Policy. ............................................................................................................................... 3

1.3. Information Collection. ..................................................................................................... 3

SECTION 2: RESPONSIBILITIES ......................................................................................................... 4

2.1. Assistant Secretary of Defense for Health Affairs (ASD(HA)). ....................................... 4

2.2. Deputy Assistant Secretary of Defense for Health Services Policy and Oversight. ......... 4

2.3. Director, Defense Health Agency (DHA). ........................................................................ 4

2.4. Secretaries of the Military Departments. .......................................................................... 5

2.5. Chairman of the Joint Chiefs of Staff. .............................................................................. 5

2.6. Geographic Combatant Commanders. .............................................................................. 6

SECTION 3: STANDARDS................................................................................................................... 7

GLOSSARY ..................................................................................................................................... 11

G.1. Acronyms. ...................................................................................................................... 11

G.2. Definitions. ..................................................................................................................... 11

REFERENCES .................................................................................................................................. 14

DoDI 6310.09, May 7, 2019

SECTION 1: GENERAL ISSUANCE INFORMATION 3

SECTION 1: GENERAL ISSUANCE INFORMATION

1.1. APPLICABILITY. This issuance applies to:

a. OSD, the Military Departments (including the Coast Guard at all times, including when it

is a Service in the Department of Homeland Security by agreement with that Department), the

Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant

Commands, the Office of the Inspector General of the Department of Defense, the Defense

Agencies, the DoD Field Activities, and all other organizational entities within the DoD (referred

to collectively in this issuance as the “DoD Components”).

b. All patients affected by sexual assault who are seen in a military treatment facility (MTF),

including children when a health care provider determines or suspects that sexual abuse has

occurred.

1.2. POLICY. The DoD will provide evidence-based health care to all patients affected by

sexual assault who are seen in an MTF or in Role 2 or Role 3 installations where a sexual assault

response coordinator is present. Care will be consistent with established community standards as

described in the:

a. Department of Justice National Protocol for Sexual Assault Medical Forensic

Examinations Adults/Adolescents.

b. National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric.

c. National Institutes of Justice National Best Practices for Sexual Assault Kits.

d. Recommendations for health care providers identified in Needs of Male Sexual Assault

Victims in the U.S. Armed Forces, including addressing issues of physical arousal, as well as

patient’s concerns about sexual orientation, as applicable.

1.3. INFORMATION COLLECTION. The DD Form 2911, “DoD Sexual Assault Forensic

Examination (SAFE) Report,” discussed in Paragraph 2.6. is exempt from licensing in

accordance with the procedures in Volumes 1 and 2 of DoD Manual 8910.01.

DoDI 6310.09, May 7, 2019

SECTION 2: RESPONSIBILITIES 4

SECTION 2: RESPONSIBILITIES

2.1. ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS (ASD(HA)).

Under the authority, direction, and control of the Under Secretary of Defense for Personnel and

Readiness, the ASD(HA) allocates funds and oversees DoD compliance with this issuance.

2.2. DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR HEALTH SERVICES

POLICY AND OVERSIGHT. Under the authority, direction, and control of the ASD(HA), the

Deputy Assistant Secretary of Defense for Health Services Policy and Oversight:

a. Develops policy and provides leadership, guidance, and oversight for the health care

management of all patients described in Paragraph 1.2.b. in the Direct Care System (DCS).

b. Consults with subject matter experts from the DoD Components, the Public Health

Service, and the United States Coast Guard, individually or in organized meetings as appropriate,

about policies related to the health care management of patients affected by sexual assault.

c. Develops performance measures, provides guidance for development of metrics, and

monitor metrics implementation and analysis related to policy implementation.

2.3. DIRECTOR, DEFENSE HEALTH AGENCY (DHA). Under the authority, direction,

and control of the Under Secretary of Defense for Personnel and Readiness, through the

ASD(HA), and in coordination with the Secretary of the Military Departments and Combatant

Commanders, the Director, DHA:

a. Develops and issues procedural guidance to ensure policy implementation.

b. Ensures Military MTFs notify patients before their sexual assault disclosure that providers

must make an immediate notification of their sexual assault disclosure to the sexual assault

response coordinator or sexual assault prevention and response victim advocate, or other

appropriate response personnel as indicated, in accordance with DoDI 6495.02, DoDI 6400.01,

DoDI 6400.06, DoDI 5505.18 and Paragraph 3.6.e. Where standard operating procedures of a

facility require informed consent in advance of treatment, the informed consent may include the

requirements for the mandatory disclosures discussed in Paragraph 3.1.f.(5).

c. Ensures providers are trained to deliver trauma-informed, gender-responsive, and

competent health care during encounters with patients described in Paragraph 3.1.

d. Ensures standardized annual training and support resources are developed and available

for all health care personnel who may encounter patients described in Paragraph 3.1.

e. Ensures the Psychological Health and Readiness Council, via the Sexual Assault Advisory

Group, identifies and responds to gaps in training, research, treatment, and health care

procedures related to the mental health needs of patients who disclose sexual assault.

DoDI 6310.09, May 7, 2019

SECTION 2: RESPONSIBILITIES 5

f. Establishes quality assurance processes and quality control metrics to ensure uniform

implementation across all DoD Components and monitoring of health care management of

sexual assault.

g Ensures that contracts or scripts for health care support and helpline services require all

contract personnel to abide by DoD reporting policy for Service members and others entitled to a

Restricted Report of sexual assault. Specifically, contractors may not undertake any action that

detracts from a person’s ability to make a Restricted Report, except in situations where a

Restricted Report is not possible as described in DoDI 6495.02.

h. Establishes guidelines and procedures to require that an adequate supply of resources, to

include personnel, supplies, and sexual assault medical forensic evidence and collection tools

(referred to in this issuance as “SAFE kits”), is maintained in all locations where SAFEs may be

conducted by DoD, including deployed locations.

2.4. SECRETARIES OF THE MILITARY DEPARTMENTS. The Secretaries of the

Military Departments, in coordination with the Director, DHA; and the Combatant Commanders:

a. Develop and issue procedural guidance to ensure adoption and implementation of this

policy.

b. Establish policies and procedures necessary for Service implementation of the

requirements of this issuance.

c. Ensure that all health care personnel receive both initial and refresher training on

procedures that are developed.

d. Direct the proper handling of SAFE kits containing forensic evidence corresponding to

both Restricted and Unrestricted Reports in deployed environments including that these SAFE

kits:

(1) Will not be held or stored in the deployed environment for longer than 5 days unless

unable to transfer to appropriate location due to operational considerations.

(2) Will be transferred to maintain established chain of custody procedures consistent

with Service regulations to a non-deployed location as determined specific to their Service

requirements.

2.5. CHAIRMAN OF THE JOINT CHIEFS OF STAFF. The Chairman of the Joint Chiefs

of Staff:

a. Takes appropriate actions to incorporate this issuance into relevant joint doctrine, training,

and plans, as appropriate.

b. In consultation with the Combatant Commanders and the Secretaries of the Military

Departments, monitor the implementation of this issuance.

DoDI 6310.09, May 7, 2019

SECTION 2: RESPONSIBILITIES 6

2.6. GEOGRAPHIC COMBATANT COMMANDERS. Through the Chairman of the Joint

Chiefs of Staff as appropriate, and in coordination with the Director, DHA; and the Secretaries of

the Military Departments:

a. Provide input to the DHA’s development of procedural guidance to ensure policy

implementation.

b. Provide trauma-informed, gender responsive, and competent health care and access to the

services of a sexual assault medical forensic examiner (SAMFE) to patients who disclose a

sexual assault to their health care provider during the course of health care in a deployed

environment when one is reasonably available. If not available in the deployed setting the

patient will be referred for medical evacuation on an emergency basis in order to receive the

necessary medical, legal, pastoral, and psychological care necessary for victims of a sexual

assault or required when treating persons accused of sexual assault. These patients will be given

the same medical priority as those who require emergency medical treatment within the

capability of the platform to which they are assigned and in consideration of the operational

activity of the unit.

c. Assign accountability for collection, documentation, and chain of custody of SAFE kit

materials and specimens to the continental United States from deployed locations in accordance

with Service regulations.

d. Develop processes to protect the privacy and confidentiality of patients who disclose a

sexual assault while in theater.

e. Establish processes to ensure the treatment of patients who disclose a sexual assault while

in theater is done emergently.

f. Assign accountability for collection, documentation, and chain of custody of SAFE kit

materials and specimens corresponding to both Restricted and Unrestricted Reports to the

continental United States from deployed locations in accordance with Service regulations.

g. Establish guidelines and procedures to require that an adequate supply of resources, to

include personnel, supplies, and SAFE kits, is maintained in deployed locations where a trained

SAMFE provider is present, otherwise a plan should be in place to emergently medically

evacuate sexual assault victims as soon as operationally feasible to a location with a trained

SAMFE and all of the other medical, psychological, pastoral, legal and counseling services

required to provide the holistic care that sexual assault victims need.

h. Ensure that forensic evidence collected and packaged using a SAFE kit for both Restricted

and Unrestricted reports are not being held or stored in the deployed environment for longer than

5 days unless unable to transfer to the appropriate location due to operational considerations and

are transferred to maintain established chain of custody procedures consistent with Service

regulations to a non-deployed location as determined by the Secretaries of the Military

Departments specific to their Service requirements.

DoDI 6310.09, May 7, 2019

SECTION 3: STANDARDS 7

SECTION 3: STANDARDS

3.1. The standards will apply to all health care providers who encounter patients who:

a. Disclose they were sexually assaulted.

b. Disclose they committed a sexual assault.

c. Are accused of committing a sexual assault.

d. Are children who the health care provider suspects have been sexually abused.

3.2. DoD will maintain confidentiality of health care information as described in DoD Manual

6025.18 and to the extent authorized by applicable laws.

3.3. Only health care providers who are appropriately trained may conduct SAFEs and must be:

a. Certified by their Service as a SAMFE that includes completion of a standardized DoD

training program; or

b. Certified by other nationally recognized certification bodies to perform SAFEs; and

c. Competent to continue to conduct the SAFE after initial certification, as demonstrated by

completion of refresher DoD training every 3 years that assures skill proficiency by an

operational provider within the operational setting without a SAMFE assigned to an operational

setting having to leave during a mission.

3.4 All MTFs will have a written plan for health care personnel who may encounter patients

described in Paragraph 3.1. The plan must ensure:

a. MTFs that operate an emergency department (ED) and provide medical care 24 hours a

day, 7 days a week will:

(1) Have at a minimum, one full-time equivalent SAMFE assigned within the MTF.

(2) Ensure that a qualified SAMFE is available to provide services on site to the MTF at

all times.

b. MTFs that do not operate ED facilities 24 hours a day, 7 days a week will include, as an

addition to their written plan, an executed memorandum of understanding or memorandum of

agreement with local private or public sector entities to ensure that patients have 24 hours a day,

7 days a week access to SAFEs performed by a person certified to perform SAFEs.

c. Contracted health care support and helpline services must abide by DoD reporting policy

for Service members and others entitled to a Restricted Report of sexual assault. Specifically,

DoDI 6310.09, May 7, 2019

SECTION 3: STANDARDS 8

contractors may not undertake any action that detracts from a person's ability to make a

Restricted Report, except in situations where a Restricted Report is not possible as described in

DoDI 6495.02.

3.5. All health care personnel who may encounter patients as described in Paragraph 3.1 will

receive initial and annual training that includes the processes in the written plan described in

Paragraph 3.4., including:

a. Each staff member’s responsibilities and mandatory reporting requirements.

b. Basic information on sexual assault, categories of reporting, and gender-responsive and

trauma-informed approaches for responding to patients, including how the experience of sexual

assault and treatment needs vary by gender.

c. Content on how to appropriately address the patient’s physical and behavioral health

needs.

d. Gender differences in how patients might present to health care personnel, including

male-specific distinctions such as reporting their experience as hazing or other forms of violence

rather than as a sexual assault.

e. Direction to consult the local medical-legal counsel for reporting requirements when

patients disclose that they have committed a sexual assault.

3.6. During the course of a health care visit, patients described in Paragraph 3.1. who seek health

care in the DCS will:

a. Receive a gender responsive, trauma-informed, culturally competent and recovery-

oriented response that ensures both female and male-specific treatment needs are

comprehensively assessed and addressed.

b. Be given priority for DCS appointments and ED care:

(1) If an eligible patient discloses that they have been sexually assaulted. The patient

will be given priority as an emergency case (triaged in the category of life-threatening

emergency responses) when presenting to an ED for sexual assault, in accordance with

DoDD 6495.01 and DoDI 6495.02.

(2) In order to preserve evidence. If the patient discloses that they have committed a

sexual assault, the patient will be offered an urgent care appointment and be given priority as an

emergency case (triaged in the category of life-threatening emergency responses) when

presenting to an ED.

(3) When accompanied by Military Criminal Investigative Organization investigators or

other DoD Law enforcement officers. Following an accusation of having committed a sexual

assault, the patient will be given priority as an emergency case (triaged in the category of life-

DoDI 6310.09, May 7, 2019

SECTION 3: STANDARDS 9

threatening emergency responses), in order to preserve evidence and assure a timely physical

assessment and SAFE are performed.

c. Be offered the services of a certified health care provider who has been appropriately

trained to perform sexual assault forensic exams as set forth in Paragraph 3.3.

d. Be advised that they may decline services of a SAMFE, except when mandated by a

search warrant or other legal order. Patients will also be advised that if eligible, they will be

provided with health care and other support services as needed and that those services may be

declined.

e. Be advised before their sexual assault disclosure (Restricted or Unrestricted) that

providers must make an immediate notification of the sexual assault in certain cases:

(1) If the patient is an active duty Service member, a member of the National Guard or

Reserves or a dependent 18 years or older of an active duty Service member and the assault was

not by an intimate partner, the assault will be reported to the sexual assault response coordinator

or sexual assault prevention and response victim advocate, in accordance with DoDI 6495.02.

(2) If the patient is a child (under 18 years old) suspected of being sexually abused, or

the patient discloses a sexual assault by a spouse or intimate partner, the abuse/assault will be

reported to the Family Advocacy Program in accordance with DoDI 6400.01 and DoDI 6400.06.

f. Be advised before a sexual assault disclosure, that a health care provider may report the

sexual assault to appropriate authorities should it be determined that there may be a serious or

imminent threat to health or safety.

g. Be advised before a sexual assault disclosure that providers may make an immediate

notification of the sexual assault in certain cases in accordance with DoD Manual 6025.18.

h. Be offered, when eligible, the opportunity to meet with appropriate personnel (e.g.

advocates from an appropriate program) as necessary.

3.7. SAFE kits:

a. Will be standardized across DoD, including in deployed settings, to ensure that the same

collection tools and instructions are used throughout the DCS.

b. That have been used and contain forensic evidence will not be held or stored in the

deployed environment for longer than 5 days unless unable to transfer to the appropriate location

due to operational considerations and must be transferred to maintain established chain of

custody procedures consistent with Service regulations to a non-deployed location as determined

by the Secretaries of the Military Departments specific to their Service requirements.

c. Must meet the established community standards as described in Paragraph 1.2. when the

SAFE is provided under a memorandum of understanding or memorandum of agreement.

DoDI 6310.09, May 7, 2019

SECTION 3: STANDARDS 10

3.8. DD Form 2911 or other forensic examination forms or protocols regarding medical forensic

evidence collection will be retained for 50 years in both Restricted and Unrestricted Report cases

in accordance with Section 1723 of Public Law 113-66. This requirement applies to any forensic

report forms received from civilian facilities and any future forms or protocols for documenting

SAFES that DoD may use as a substitute for DD Form 2911.

DoDI 6310.09, May 7, 2019

GLOSSARY 11

GLOSSARY

G.1. ACRONYMS.

ASD(HA) Assistant Secretary of Defense for Health Affairs

DCS Direct Care System

DHA Defense Health Agency

DoDD DoD directive

DoDI DoD instruction

ED emergency department

MTF military treatment facility

SAFE sexual assault medical forensic examination

SAMFE sexual assault medical forensic examiner

G.2. DEFINITIONS. Unless otherwise noted, these terms and their definitions are for the

purpose of this issuance only.

DCS. Defined in DoDI 6025.20

ED. The section of a medical treatment facility that treats patients with acute conditions without

an appointment, either by their own means or by ambulance. EDs can be found in hospitals or

clinics within the DCS.

family advocacy program. Defined in DoDI 6400.06.

gender-responsive care. Defined in DoDD 6495.01

health care provider. Individuals who are employed or assigned as healthcare professionals, or

are credentialed to provide healthcare services at an MTF, or who provide such care at a

deployed location or otherwise in an official capacity. This also includes military personnel and

DoD civilian employees, who provide healthcare at an occupational health clinic for DoD

civilian employees or DoD contractor personnel. This includes:

(1) Physician.

(2) Nurse practitioner.

(3) Nurse midwife.

(4) Physician assistant.

(5) Registered nurse.

DoDI 6310.09, May 7, 2019

GLOSSARY 12

(6) Independent duty corpsmen or equivalent health care personnel who may be assigned to

duty as SAMFE if assignment of personnel in categories (1)-(5) to SAMFE is impractical.

Restrict the use of independent duty corpsmen as SAMFE providers to only those rare cases

where they are the only available DoD provider, the remainder of the sexual assault victim

services are available, and it is impractical or impossible to obtain the SAFE in the foreign

civilian health care setting without risking re-victimizing the victim.

health care personnel. Defined in DoDI 6495.02.

informed consent. Defined by the Joint Commission (https://www.ama-assn.org/delivering-

care/ethics/informed-consent).

Restricted Reporting. Defined in DoDD 6495.01.

SAFE kit. The collection tools, usually packaged in the form of a boxed kit that includes

collection containers, bags, measuring devices and other equipment along with the instructions

used to gather medical forensic evidence during the sexual assault medical forensic examination.

It also refers to the evidence, usually returned to the box and sealed, once collected. When used,

it is a forensic product which is created through the process of evidence collection.

sexual assault. Intentional sexual contact characterized by the use of force, threats, intimidation,

or abuse of authority or when the victim does not or cannot consent. The term includes a broad

category of sexual offenses consisting of the following specific Uniform Code of Military Justice

offenses: rape, sexual assault, aggravated sexual contact, abusive sexual contact, forcible

sodomy (forced oral or anal sex), or attempts to commit these offenses.

SAFE. A medical-forensic examination of a sexual assault patient (victim or suspect) by a

specially trained healthcare provider known as a SAMFE. The SAFE includes a medical-

forensic history; physical examination; collection of evidence, documentation of biological and

physical findings; and evaluation and treatment of sexually transmitted infections, pregnancy,

suicidal ideation, substance abuse, and other non-acute medical concerns.

SAMFEs. Specially trained healthcare provider who has completed specialized education and

clinical preparation in the medical forensic care of the sexual assault patient. SAMFEs are

trained to provide sexual assault patient care in accordance with Department of Justice training

standards and have completed training through the DoD inter-Service SAMFE training program

or other DoD approved organization and are credentialed by their Service or other DoD agency

to perform SAFEs within the MHS.

sexual assault response coordinator. Defined in DoDD 6495.01.

sexual assault prevention and response victim advocate. Defined in DoDD 6495.01.

trauma-informed care. An approach to engage people with histories of trauma that recognizes

the presence of trauma symptoms and acknowledges the role that trauma has played in their

lives. Trauma-informed services are based on an understanding of the vulnerabilities or triggers

of trauma survivors that traditional service delivery approaches may exacerbate, so that these

services and programs can be more supportive and avoid re-traumatization.

DoDI 6310.09, May 7, 2019

GLOSSARY 13

Unrestricted Reporting. Defined in DoDD 6495.01.

DoDI 6310.aa, Publication Month Day, Year

REFERENCES 14

REFERENCES

American Medical Association Website “Informed Consent”

Department of Justice, A National Protocol for Sexual Assault Medical Forensic Examinations –

Adults/Adolescents, Second Edition, or current version

Department of Justice, A National Protocol for Sexual Abuse Medical Forensic Examinations-Pediatric,

or current version

Department of Justice, National Training Standards for Sexual Assault Medical Forensic Examiners, or

current version

DoD Directive 5124.02, Under Secretary of Defense for Personnel and Readiness (USD(P&R)),”

June 23, 2008

DoD Directive 6495.01 “Sexual Assault Prevention and Response (SAPR) Program”, January 23, 2012,

as amended

DoD Instruction 5505.18, “Investigation of Adult Sexual Assault in the Department of Defense,”

March 22, 2017, as amended

DoD Instruction 6025.20, “Medical Management (MM) Programs in the Direct Care System (DCS) and

Remote Areas,” April 9, 2013, as amended

DoD Instruction 6400.01, “Family Advocacy Program (FAP),” May 1, 2019

DoD Instruction 6400.06, “Domestic Abuse Involving DoD Military and Certain Affiliated Personnel,”

August 21, 2007, as amended

DoD Instruction 6495.02, “Sexual Assault Prevention and Response (SAPR) Program Procedures,”

March 28, 2013, as amended

DoD Manual 6025.18, “DoD Health Information Privacy Regulation,” March 13, 2019

DoD Manual 8910.01, Volume 1, “DoD Information Collections Manual: Procedures for DoD Internal

Information Collections,” June 30, 2014, as amended

DoD Manual 8910.01, Volume 2, “DoD Information Collections Manual: Procedures for DoD Public

Information Collections,” June 30, 2014, as amended

National Institute of Justice, “National Best Practices for Sexual Assault Kits: A Multidisciplinary

Approach”, or current version

Public Law 113-66, Section 1723, “Retention of Certain Forms in Connection with Restricted Reports

and Unrestricted Reports on Sexual Assault Involving Members of the Armed Forces,” December

26, 2013

Public Law 113-66, Section 1725, “Qualifications and Selection of Department of Defense Sexual

Assault Prevention and Response Personnel and Required Availability of Sexual Assault Nurse

Examiners,” December 26, 2013

Located at https://www.ama-assn.org/delivering-care/ethics/informed-consent

Located at https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf

Located at https://www.justice.gov/ovw/file/846856/download

Located at https://www.justice.gov/ovw/page/file/1090006/download

REFERENCES 15

DoDI 6310.09, May 7, 2019

Public Law 113-291, Section 538, “Requirements Relating to Sexual Assault Forensic Examiners for the

Armed Forces,” December 19, 2014

Public Law 114-92, Section 538, “Improved Department of Defense Prevention and Response to Sexual

Assaults in which the Victim is a Male Member of the Armed Forces,” November 25, 2015

Public Law 114-92, Section 539, “Preventing Retaliation Against Members of the Armed Forces Who

Report or Intervene on Behalf of the Victim of an Alleged Sex-Related Offence,” November 25,

2015

RAND National Security Research Division, “Needs of Male Sexual Assault Victims in the U.S. Armed

Forces,” 2018

Located at:

https://www.rand.org/content/dam/rand/pubs/research_reports/RR2100/RR2167/RAND_RR2167.appendixes.pdf