I, (Insert name of victim here.) under oath do hereby apply to the Court and further depose and say as follows:

      1.       I am the victim of a sexual assault that poses a risk of transmission of a sexually transmitted disease. Specifically, I was (Insert the type of offense here. For example, "Sexual Act" at 18 U.S.C. 2246(2)(A-C) or "Sexual Abuse of a Minor" at 18 U.S.C. 2246(2)(D), etc.), by (Insert name of defendant here.) (hereinafter referred to as "defendant"). I have been informed by (Insert name of the medically trained counselor here.) that this conduct creates a risk of transmission, as determined by the Centers for Disease Control, of the etiologic agent for acquired immune deficiency syndrome.

      2.       There exists probable cause to believe that the defendant has committed a Federal offense of (Insert the type of offense that appears in the indictment, information, or complaint here.) in violation of (Insert the United States Code violation here.). An attested copy of documentation reflecting that such probable cause exists is attached hereto and is incorporated herein.

      3.       I hereby request that the defendant be tested for the etiologic agent for acquired immune deficiency syndrome, in accordance with Title 42 U.S.C. Section 14011(b).

      4.       I hereby request that if the initial test of the defendant for the etiologic agent for acquired immune deficiency syndrome is negative, that the defendant be re-tested six (6)months and again twelve (12) months following the initial test, in accordance with Title 42 U.S.C. Section 14011(b)(3).

      5.       I have received appropriate counseling on the accuracy of such tests and the risks of transmission of sexually transmitted diseases as the result of a sexual assault. I am advised that the tests I request would provide information necessary for my health.

      WHEREFORE, I respectfully petition this Court: 1) To order the defendant to appear, or in the event that defendant is in custody, that the Court direct the United States Marshal for this district to produce the defendant before you; 2) that after a hearing, the Court direct the defendant to submit to testing for the presence of the etiologic agent for acquired immune deficiency syndrome; 3) to order the defendant to be re-tested six months and again twelve months following the initial test, if the initial test is negative; and 4) that after the completion of the said tests, the entity conducting the tests provide the test results to me.

      I further request that the Court seal this Petition, any Order filed as a result thereof, any docket entries and other records created thereby except as to me, the defendant, the entity who is to perform the tests, and such officers and agents of the Court as are necessary to carry out this Order.

      This matter comes before me, upon the Petition of __________________. After notice and hearing or opportunity therefor, I can and do find:

      1.       That there exists probable cause to believe that (Insert name of defendant here.) has committed the crime of ______________________________, in violation of ____________________, a sexual assault.

      2.       That such conduct has exposed the Petitioner to the risk of a transmission, as determined by the Centers for Disease Control, of the etiologic agent for acquired immune deficiency syndrome.

      3.       That the Petitioner, after appropriate counseling, has requested that the defendant be tested for the presence of the etiologic agent for acquired immune deficiency syndrome, in accordance with Title 42 U.S.C. Section 14011(b).

      4.       That the Petitioner, after appropriate counseling, has also requested that if the initial test for the etiologic agent for acquired immune deficiency syndrome is negative, that the defendant be re-tested six (6) months and twelve (12) months following the initial test, in accordance with Title 42 U.S.C. Section 14011(b)(3).

      5.       That such tests would provide information necessary for the Petitioner's health.

      6.       That the Petitioner's application and affidavit establish good cause for the sealing of the application, this Order, any docket entries created thereby, and the record of this proceeding.

      1.       The defendant shall submit to tests for the presence of the etiologic agent for acquired immune deficiency syndrome;

      2.       If the defendant is in custody, the United States Marshals Service officer or other officer shall produce the defendant at an appropriate location for the execution of such testing;

      3.       If the defendant is not in custody, the defendant shall submit to such testing at an appropriate location, which may include a locally accessible free testing facility;

      4.       The entity performing the tests shall provide the results thereof to the Petitioner and the defendant;

      5.       The Petitioner shall not disclose the results of such testing to any person other than a medical professional, counselor, family member, or a sexual partner the Petitioner may have had since the date of the sexual assault. Further, the Petitioner shall advise any such person(s) that such person(s) shall not make further disclosure of the said test results and that the terms of this Order shall apply to such person(s) as though entered against such person(s) personally;

      6.       The Clerk shall seal this Order, the Petition, the docket entries, and any other records of this proceeding and shall not make disclosure thereof other than to the parties and individuals or entities whom the Clerk deems necessary to carry out this Order. SO ORDERED.

What you need to know about HIV and other STDs

• There are many common sexually-transmitted diseases (STDs), including gonorrhea, syphilis, chlamydia, genital warts, herpes, and HIV (the AIDS virus).

• Proper testing is the only way to know if you are infected.

• STDs, including HIV, usually are passed through vaginal, oral, or anal intercourse. However, some STDs can be passed from skin-to-skin contact in the genital area.

• An infected woman can pass HIV to her baby through breast milk.

• Many STDs can be cured easily especially if they are found early.

• HIV is fairly hard to get from a single sexual act. There are only a few cases of HIV infection from sexual assault. You are more likely to get other STDs from a single contact with an infected person.

• Signs of STDs may not show up right away. Some people never notice any signs of infection. This is especially true for women.

Your private doctor can test you for HIV and other STDs or you can go to a clinic. The following confidential clinics are in the area:

Clinic Numbers

For more information contact:
Victim Witness Assistance Unit United States Attorney's Office

Impact of sexual assault

Sexual assault can be an extremely traumatic experience. You may have been hurt both physically and emotionally. Feelings of anger, guilt, shame, and fear are common reactions. In addition to dealing with these strong emotions, you may also be concerned about being infected with a sexually transmitted disease or HIV, the virus that causes AIDS.

This brochure provides you with information about sexually transmitted diseases and available medical counseling services to help you deal with your concerns. Remember: It is not your fault. You are not alone.

Testing for STDs and HIV

If you did not get immediate medical attention after the sexual assault, get a full check up for STDs, including HIV, right away. A rape examination usually includes STD tests. If STD and HIV testing are not available, you should go to another clinic for a test as soon as possible.

Most medical clinics, hospitals, and private physicians will test for STDs and HIV. Some clinics and public hospitals will do the testing free of charge. Clinic telephone numbers are listed on this brochure. If the case is being investigated or prosecuted by a Federal Government agency, you are entitled to testing at no cost to you. Certain requirements apply. Check with the Victim Witness Assistance Unit for details and procedures.

Many STDs take several days to several months to show up. If an STD is diagnosed at an exam done right after the assault, you probably had the STD before the assault. The infection could be from past sexual contact or drug use. Talk to your health care provider about taking medicine and telling partners. If your first tests are negative, you may be able to rule out the possibility that you had an STD before the assault.

Even if your tests are negative, get tested again in 3 to 6 months. You cannot be sure if you have HIV or another STD unless you get tested at least 3 months after the assault. It can take up to 6 months after infection for antibodies to show up on a test. The U.S. Attorney's Office can assist you in obtaining this second test at no cost to you. Your health and peace of mind are worth it!

While waiting for the test results, it is normal to feel anxious and worried. Your counselor or doctor may be able to help. During this time, you need to protect your health and your loved ones from infection.

Testing and confidentiality

It is important to be tested in a facility that offers counseling and protects your confidentiality. STD and HIV tests usually are free in public health clinics.

You have the right to have up to two confidential and anonymous tests following a sexual assault that poses a risk of transmission of HIV virus or an STD. Test results are not given over the phone or sent in the mail. The nurse who drew your blood will give you the test results on your second visit and explain them to you in private.

Counseling and information

Most sexual assault crisis centers have hotlines operated by trained counselors who understand sexual assault and will talk to you confidentially. Most medical centers also provide counseling. Or, a Victim Witness Advocate in the U.S. Attorney's Office will help you make arrangements for counseling.

HIV testing and the perpetrator of sexual assault

A judge can order a person charged with a sexual assault to be tested for HIV if the victim requests this through the Assistant U.S. Attorney. You will be given the results; however, you are allowed to share this information ONLY with your doctor, counselor, family members, and any sexual partners you may have had after the assault.

Regardless of the perpetrator's test, you still need to have your own HIV test. Even if the perpetrator has HIV, you may not have been infected during the sexual assault. If the perpetrator's HIV test is negative, the perpetrator could still have HIV. Recent infections (within 3-6 months) may not show up on his test. People with HIV can infect others at any time, even before their own blood shows signs of HIV.