Victorian Institute of Forensic Medicine

Victorian Institute of Forensic Medicine

VIFM CASE DETAILS FORM
PRACTITIONER NAME: ______
DETAILS OF PERSON EXAMINED / Please complete ALL unshaded areas
Surname / VIFM Case No. (office use only)
Given Name
Date of Birth / Male / Female (please circle) / Postcode
REQUESTING AGENCY / Please complete ALL unshaded areas
Contact Name / Rank / Member No.
Agency/Squad / Location / Phone No.
SERVICE DETAILS / Please complete ALL unshaded areas
FACILITY (e.g. CASA, police station) / SUBURB
DATE of SERVICE / CALL OUT Type / CONSULTATION Type
CALL RECEIVED* / Use 24 hr clock / Please select from below: / Please select from below:
TRAVEL COMMENCED / : / □  Sexual Assault
□  Sexual Assault Recent
(Where a victim presents to police within 72 hrs of incident)
□  Sexual Assault Offender
□  Physical Assault
□  Police Assault ( on / by )
□  Fitness for Interview
□  Traffic Medicine
□  Other (please give detail)
______ / □  Clinical Examination
□  Biological Specimens
□  Court Appearance
half OR full day (please circle)
□  Expert Opinion
□  Other (please give detail)
______
ARRIVED at CASE* / :
* If you arrived at case more than:
¨  2 hrs (Sexual Assault Examinations) or
¨  3 hrs (all other Examinations & Biological Specimens)
after Time CALL RECEIVED please provide detail in your notes
CASE COMMENCED include pre-consultation with Police/Hospital / :
CASE CONCLUDED / :
TRAVEL CONCLUDED / :
¨ After Hours ¨ Delays (please give detail) ¨ Cancelled (please give detail) ¨ CFM Clinic
Notes: ______
______
CONFLICT OF INTEREST / If you identify a conflict of interest, real or potential, please complete the following section to confirm acceptance to commence case. (Provide detail in your notes)
Senior On-Call contacted: Y / N / Name of Senior: / Senior On-Call acceptance: Y / N
BUDDY CASE (Any accompanying VIFM health personnel) / Who: / Role:
ADDITIONAL CASE NOTES
Patient contact details:
Consent:
I ……………………………………………………… hereby consent to: (delete those not applicable)
Ø  Examination
Ø  Collection of specimens
Ø  Police report
Ø  Photography
Ø  Release of forensic specimens to Police.
on …………………………………… Signature ………………………………………………………
SAMPLES:
LIST: …………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………..
COLLECTED: Date ...... /…..…/…..…. Time ……………………………. hours
HANDED TO: ………………………………………………………………………………………..…………………….
Date ...... /…..…/…..…. Time ……………………………. hours
Signature: ……………………………………………………………… Date ……………………………………
SERVICE FEE CALCULATION / CFM Office Use
TOTAL TIME CLAIMED (time you left home to time you returned home) / ______mins / Signature:
______
Date: ______
REPORT PREPARED & REVIEWED BY VIFM / ¨ Simple ¨ Routine
TRAVEL TO BE REIMBURSED / ______km @ $0.____ / km

Practitioner’s Signature ______Date ______/______/______

SEND TO: VIFM, Clinical Forensic Medicine 57-83 Kavanagh Street, Southbank, Victoria, 3006

Document ID: FR-12-0002-2.0 Authorised copy of form Page 2 of 2

Date Effective: 01/07/2011