More examples in Healthcare/Medical Examination Reports
Aircraft Accident Medical Examination Example
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AIRPORT DISTANCE OF CRASH FROM NEAREST AIRPORT: FLIGHT WAS: PRIVATE COMMERCIAL AGRICULTURAL OTHER: WAS A FLIGHT PLAN FILED? NO YES IF YES, SUBPOENA AND SEND WITH INVESTIGATION WAS AIRPORT IN RADIO CONTACT? NO YES WAS DISTRESS MESSAGE RECEIVED? NO YES OTHER AGENCY INVOLVED NAME OF FAA/NTSB REPRESENTATIVE: OTHER NON -LAW ENFORCEMENT INVESTIGATORS: AGENCY: IF BODIES WERE THROWN FROM THE AIRCRAFT, BE SURE TO DRAW A DIAGRAM OF THE SCENE ON A SUPPLEMENTAL REPORT INCLUDING POSITIONS OF BODIES AS FOUND. EACH BODY BAG SHOULD BE NUMBERED AND EACH NUMBER SHOULD BE IDENTIFIED ON THE SUPPLEMENTAL REPORT. BE SURE TO COLLECT PERSONAL EFFECTS WHICH WILL FACILITATE IDENTIFICATION. AIRCRAFT PARTS ARE NOT TO BE SENT IN WITH A BODY. NAME OF INVESTIGATOR DMI# AIRCRAFT ACCIDENT NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines DECEDENT'S POSITION IN AIRCRAFT IF VICTIM REMAINED IN AIRCRAFT, POSITION IN AIRCRAFT: LEFT SIDE LEFT SIDE FRONT ROW 2ND ROW OTHER: SAFETY HARNESS (BELT): PRESENT NOT PRESENT USED NOT USED UNABLE TO DETERMINE SHOULDER STRAP: PRESENT NOT PRESENT USED NOT USED UNABLE TO DETERMINE DECEDENT WAS: PILOT CO -PILOT STUDENT PILOT OTHER: DO OTHER OCCUPANTS HAVE ANY FLIGHT EXPERIENCE? RATING TYPE: YEARS EXPERIENCE: HOURS FLYING TIME: DATE OF LAST PHYSICAL EXAM: NAME OF PHYSICIAN WHO PERFORMED LAST PHYSICAL: CONTACT INFORMATION FOR PHYSICIAN: IF THE DECEDENT WAS THROWN FROM THE AIRCRAFT, EXPLAIN HIS POSITION RELATIVE TO
THE AIRCRAFT: IF THE DECEDENT WAS THROWN FROM THE AIRCRAFT, WHAT METHOD WAS USED TO
DETERMINE HIS POSITION IN THE AIRCRAFT PRIOR TO THE CRASH? WERE OTHER FATALITIES INVOLVED: NO YES IF YES, HOW MANY: (BE SURE TO DESCRIBE EACH FATALITY ON SEPARATE PAGES.) AIRCRAFT AIRCRAFT OWNED BY: MAKE: MODEL: SER#: AIRCRAFT #: “N” NUMBER ON TAIL: SINGLE -ENGINE MULTI-ENGINE NON-ENGINE PROPELLERS JET GLIDER OTHER: AIRCRAFT WAS: LANDING TAKING OFF BETWEEN DESTINATIONS EVIDENCE OF AIRCRAFT DEFECT OR MALFUNCTION? DID THE AIRCRAFT: BURN EXPLODE TURN OVER EXPLAIN:
THE AIRCRAFT: IF THE DECEDENT WAS THROWN FROM THE AIRCRAFT, WHAT METHOD WAS USED TO
DETERMINE HIS POSITION IN THE AIRCRAFT PRIOR TO THE CRASH? WERE OTHER FATALITIES INVOLVED: NO YES IF YES, HOW MANY: (BE SURE TO DESCRIBE EACH FATALITY ON SEPARATE PAGES.) AIRCRAFT AIRCRAFT OWNED BY: MAKE: MODEL: SER#: AIRCRAFT #: “N” NUMBER ON TAIL: SINGLE -ENGINE MULTI-ENGINE NON-ENGINE PROPELLERS JET GLIDER OTHER: AIRCRAFT WAS: LANDING TAKING OFF BETWEEN DESTINATIONS EVIDENCE OF AIRCRAFT DEFECT OR MALFUNCTION? DID THE AIRCRAFT: BURN EXPLODE TURN OVER EXPLAIN: