Date Report Prepared

VIFM CLINICAL FORENSIC MEDICINE

Confidential Forensic Medical Report

Physical Assault

Date report prepared: Date

Report prepared for

RankInformant's Name

Police Unit

DX or Address

REName: Patient's full name and also known-as names

Date of birth: 28 January 1969

Author of report: Author Name

I, Examiner Name am a duly qualified Medical Practitioner/Reg Nurse (Div 1)registered in Australia. I am a Position Descriptionemployed by the Victorian Institute of Forensic Medicine at 57-83 Kavanagh Street, Southbank Victoria. My further qualifications and experience include:

Qualifications and Experience

Qualifications and Experience

Qualifications and Experience

Qualifications and Experience

Employment history and experience as it relates to this type of case

Regular attendance at professional development courses and conferences related to forensic medicine

Reason for Assessment

Attending Officer from the [station/location] rang me requesting a physical assault examination onExaminer Name following allegations of [physical assault by a known/unknown person] having occurred [xx] hours ago. The police requested documentation of injuries, photographs and collection of forensic specimens in this case.

Site and time of assessment(s)

I examined Patient's full name and also known-as namesa xx year old male/female at the Examination location on the date at time. Patient's full name and also known-as names was accompanied by accompanying person and/or police officer(s).

Consent

Name of person providing consent provided consent for the history,examination,collection of forensic and medical specimens and documentation of findings, photographyand release of a medico-legal report to police.

manner, use of forms to obtain consent, limitations in obtaining consent

Observers

Name/s of observerwas/were present for the history and the examination.

Sources of information

The information was provided by Police Officer & Rankat the time of the consultation and by the subject.

History

A history to guide the examination was taken from Police Officer & Rankwho stated the following:

On direct questioning, Patient's full name and also known-as names told me:

• Symptoms

The above history was taken in order to direct the examination and does not necessarily constitute a detailed account of the entire event.

Past Medical History

A past medical history was taken

- and of relevance to the case and my opinion was….; OR

- and contained no relevant information to the case or my opinion

Examination

Patient's full name and also known-as nameswas examined in the presence of Name(s) of Observer(s). The examination was conducted approximately xxx hours following an allegation of Type of Assault.

general appearance and relevant negatives regarding intoxication, psychiatric, symptomatology, intellectual or physical disability

The following findings were noted:

Head and Neck

Back and Buttocks

Chest and Abdomen

Right Upper Limb (hand, forearm, arm)

Left Upper Limb (hand, forearm, arm)

Right Lower Limb (thigh, leg, foot)

Left Lower Limb (thigh, leg, foot)

(Indicate any sites not examined)

Photographs

There were no photographs taken at the time of the examination.

Photograph count Photographs were taken at the time of the examination by Photographer.

A bound set of photographs accompany this report OR are contained within this report.

Medical Management

Treatment

Investigation

Referral

Consultation

Information sharing

I discussed my findings and the details of this case with:

- Police Police Officer's Name, Date

- Senior member of staff, Senior staff name, Date

Limitations to opinion

The opinion was made without obvious limitation.

My opinion is limited by the following factors: (lighting, intubation, disability etc.)

DISCUSSION

- Wound Definitions

- Anatomical Explanations

- Concepts Explained

OPINION

With respect to the above information and findings, I am of the opinion that:

- Severity

- Nature

- Consequences

- Mechanism of Injury

- Timing/ Ageing

-----etc------

The opinions given in this statement are based on the information available to me and may be subject to change if further information becomes available.

Doctor/Nurse Fullname Qualifications

Position Title

I hereby acknowledge that this statement is true and correct and I make it in the belief that a person making a false statement in the circumstances is liable to the penalties of perjury.

Doctor/Nurse Full Name Qualifications

Position Title

Acknowledgment taken and signature witnessed by me at ………….am/pm

On………………………………, the…………………………day of………………………….[year]

at the ……………………………………………………………...

Signature …………………………………………………………….

Name …………………………………………………………….

Rank/No …………………………………………………………….