(a)(1)  For the purpose of documenting incidents of family violence resulting in injuries treated at medical facilities or by medical providers and of providing statistically valid information on the extent of family violence, the domestic violence training and monitoring unit of the court system shall prescribe a form for making medical data collection reports. The form shall include, but is not limited to the following:

(i)  Relationship of the parties;

(ii)  Sex of the parties;

(iii)  Date of birth of the parties;

(iv)  Time and date of the incident;

(v)  Whether the incident is verified by the victim;

(vi)  Type of injuries;

(vii)  Whether medical attention or hospitalization is required;

(viii)  Whether the victim has previously sustained injuries as a result of family violence;

(ix)  Action taken;

(x)  Source of the report;

(xi)  Address of the reporter.

(2)  The report shall not contain the name of the parties nor any other identifying information.

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(b)  A report shall be completed for any victim being treated for injuries which the victim states resulted from domestic violence or which the mandated medical provider has reasonable cause to believe resulted from domestic violence.

(c)  The report shall be submitted to the unit on a quarterly basis for quarters ending on September 30, December 31, March 31, and June 30.