Opt-In Notification Form

* Indicates a required field

Contact Name:

Name at time of report (if different):

Victim DOB:

Contact Number:

Email Address:

Best time to contact:

Preferred method of contact:

If different than telephone, contact information:

Agency of Report (Police):

Location of collection (Hospital):

Date of Kit Collection:

Case Number:

How did you hear about SAKI:

When would you like to be notified (check all that apply):

When kit is submitted for testing

After results

After results only if identification was made

Permission to share contact number with LE:

Yes