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Medical Examination for a Carbon Monoxide Related Death Example
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CARBON MONOXIDE - RELATED DEATH NAME OF DECEDENT: This form is to be completed in addition to the ROD form in these guidelines WAS A CARBON MONOXIDE LEVEL RUN LOCALLY? NO IF YES, LAB NAME: LAB CONTACT & TELEPHONE NUMBER: CARBON MONOXIDE LEVEL: (Be sure to send copy of lab results.) AUTOMOBILE HOW WAS THE AUTO FOUND AND WHERE IS THE DECEDENT IN RELATION TO THE AUTO? IS THE AUTO IN AN ENCLOSED SPACE (GARAGE, WAREHOUSE, ETC.)? NO IF YES, IS/WAS THE FACILITY CLOSED OR SEALED EITHER FROM THE OUTSIDE OR THE INSIDE - EXPLAIN: IS THE AUTO IGNITION STILL ON: YES NO IF UNDETERMINED, EXPLAIN: IS THE AUTO BATTERY DEAD? YES NO IS THE GAS TANK EMPTY? YES NO IF NO, HOW MUCH IS LEFT? IS/WAS THE AUTO LOCKED? YES NO IF UNDETERMINED, EXPLAIN: DESCRIBE ALL PARAPHERNALIA (HOSES, ETC.) ATTACHED TO THE VEHICLE: RESIDENCE WAS INDEPENDENT AGENCY CALLED TO CHECK FACILITY FOR CO PRESENCE OR FAULTY
HEATING EQUIPMENT? NO IF YES, WHICH AGENCY AND WHAT WERE THEIR FINDINGS? DESCRIBE HEATING SOURCES: RECENT SERVICE? WHERE IS THE BODY FOUND IN RELATION TO THE ORIGIN OF THE CO SOURCE? IF GARAGE IS CONNECTED TO THE HOUSE, IS THERE EVIDENCE OF CO EXPOSURE TO VEHICLE IN
GARAGE? (ANSWER ABOVE QUESTIONS RE AUTO.) IF IN GARAGE, IS THERE A HOT WATER HEATER? NO IF YES, IS PILOT LIGHT STILL LIT? YES NO ANY OTHER SICK OR DEAD INDIVIDUALS OR ANIMALS - DESCRIBE & GIVE LOCATION IN THE RESIDENCE: NAME OF INVESTIGATOR DMI#
HEATING EQUIPMENT? NO IF YES, WHICH AGENCY AND WHAT WERE THEIR FINDINGS? DESCRIBE HEATING SOURCES: RECENT SERVICE? WHERE IS THE BODY FOUND IN RELATION TO THE ORIGIN OF THE CO SOURCE? IF GARAGE IS CONNECTED TO THE HOUSE, IS THERE EVIDENCE OF CO EXPOSURE TO VEHICLE IN
GARAGE? (ANSWER ABOVE QUESTIONS RE AUTO.) IF IN GARAGE, IS THERE A HOT WATER HEATER? NO IF YES, IS PILOT LIGHT STILL LIT? YES NO ANY OTHER SICK OR DEAD INDIVIDUALS OR ANIMALS - DESCRIBE & GIVE LOCATION IN THE RESIDENCE: NAME OF INVESTIGATOR DMI#