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Medical Examination for Childhood Abuse-Neglect Example
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CHILDHOOD - ABUSE/NEGLECT NAME OF DECEDENT: This form is to be completed in addition to the ROD form in these guidelines CIRCUMSTANCES OF DEATH INFORMANT NAME: TEL #: RELATIONSHIP TO DECEDENT: DESCRIBE WHAT HAPPENED: WHAT WAS THE CHILD SUPPOSED TO BE DOING? WAS THE CHILD LEFT ALONE FOR ANY PERIOD OF TIME? NO IF YES, EXPLAIN: WAS ONE PARENT ABSENT AT THE TIME OF T HE INCIDENT? NO IF YES, FOR HOW LONG, AND WHERE WERE THEY? DESCRIBE INITIAL ACTIONS TAKEN BY DISCOVERER(S): WAS THERE AN APPARENT TIME DELAY BETWEEN THE TIME THE DECEDENT WAS BELIEVED TO BE
DEAD AND WHEN THE DEATH WAS ACTUALLY REPORTED (EXPLAIN)? HAVE ANY OF THE OUT -OF-HOME RELATIVES OF THE FAMILY BEEN CONTACTED? NO IF YES, WHO AND WHAT WAS THEIR RESPONSE TO THE DEATH? HOW DO PARENTS OR OTHER FAMILY MEMBERS DESCRIBE THE DECEDENT? THE SCENE IF EVENT OCCURRED IN A RESIDENCE, DESCRIBE THE SURROUNDING COMMUNITY: DOES THE RESIDENCE EXHIBIT: FOUL ODORS RODENT OR INSECT INFESTATION SAFETY HAZARDS ( SUCH AS EXPOSED ELECTRICAL CORDS, ETC) ARE THERE ANY SIGNS OF DRUGS OR ALCOHOL USE IN THE RESIDENCE? NO IF YES EXPLAIN: IF TOYS, FURNITURE, PLAYGROUND EQUIPMENT, ETC., IS INVOLVED, DESCRIBE AND
PHOTOGRAPH: WHAT ARTICLES ARE COLLECTED AS EVIDENCE AND WHERE ARE THEY? DO THE ARTICLES HAVE OBVIOUS BLOOD OR TISSUE PRESENT ON THEM? MEDICAL HISTORY HOSPITAL(S)/CLINIC(S) WHERE DECEDENT HAS BEEN SEEN: NAME: CITY: NAME: CITY: OTHER TREATING PHYSICIAN(S): TEL# WAS THIS CHILD THE RESULT OF A PLANNED PREGNANCY? NO YES UNK DID MOTHER OF THE CHILD HAVE ROUTINE PRENATAL CARE DURING HER PREGNANCY? NO YES UNK WERE THERE ANY PROBLEMS OR UNUSUAL EVENTS DURING THE PREGNANCY? NO IF YES, EXPLAIN: BIRTH WEIGHT OF CHILD? HAS THE CHILD'S GROWTH AND DEVELOPMENT BEEN NORMAL SINCE BIRTH? YES IF NO, EXPLAIN: WERE HOSPITALS CHECKED TO SEE IF THEY HAVE RECORDS OF TREATMENT FOR TRAUMA OF
ANY OF THE CHILDREN? DESCRIBE PHYSICIAN'S GENERAL OBSERVATIONS ABOUT THE CHILD: IS THERE A SOCIAL/CASEWORKER INVOLVED? AGENCY: SOCIAL WORKER/CASE WORKER: TEL# AGENCY NOTIFIED OF DEATH BY: INFORMATION GATHERED FROM SOCIAL OR CASE WORKER INCLUDING PREVIOUS RESPONSES TO RESIDENCE: HAVE THE POLICE EVER BEEN DISPATCHED TO FAMILY (AT ANY GIVEN RESIDENCE) FOR ANY
REASON WHATSOEVER? NAME OF INVESTIGATOR DMI# FAMILY STRUCTURE ARE NATURAL PARENTS: TOGETHER SEPARATED DIVORCED WIDOWED MOTHER: DOB: MAIDEN NAME (ALIASES ): FATHER: DOB: ALIAS(ES ): WAS CHILD LIVING WITH: MOTHER FATHER OTHER: IF CHILD WAS LIVING WITH ONE PARENT, WAS THAT PARENT LIVING WITH A SIGNIFICANT
OTHER? NO IF YES, NAME: DOB: SIGNIFICANT OTHER'S MAIDEN NAME (ALIASES) IF APPLICABLE: IF LEGAL GUARDIAN: NAME: DOB: LEGAL RELATIONSHIP: IS EITHER PARENT ROUTINELY ABSENT (EXPLAIN)? WHO IS PRIMARY CARETAKER IF PARENT WORKS (NAME/ADDRESS/TELEPHONE# & RELATIONSHIP TO DECEDENT)? NAMES OF OTHER ADULT RELATIVES OR ACQUAINTANCES LIVING IN OR VISITING THE
HOUSEHOLD AND THEIR RELATIONSHIP TO PARENTS OR DECEDENT: ARE ANY CAREGIVERS ON MEDICATION – EXPLAIN: SIBLINGS (AGE & SEX): ARE ALL OF THE LIVEBORN CHILDREN OF THESE PARENTS STILL LIVING? YES NO (EXPLAIN INCLUDING DATES, ETC.) IF NOT LIVING IN HOUSE, WHERE? WHAT IS THE APPARENT PHYSICAL/EMOTIONAL STATUS OF OTHER CHILDREN? DESCRIBE CLOTHING OF PARENTS AND OTHER LIVE CHILDREN IN RELATION TO CLOTHING OF
THE DECEDENT: DESCRIBE THE APPARENT DEGREE OF CARE PROVIDED FOR LIVE CHILDREN: DESCRIBE THE OTHER CHILDREN'S REACTION TO THE DEATH: HAS THE FAMILY STRUCTURE CHANGED SINCE THE BIRTH OF THE CHILD? HAVE THE CARETAKERS LIVED IN OTHER AREAS OF THE STATE OR COUNTRY (WHERE & WHEN -
FROM MOST RECENT BACKWARD)?
DEAD AND WHEN THE DEATH WAS ACTUALLY REPORTED (EXPLAIN)? HAVE ANY OF THE OUT -OF-HOME RELATIVES OF THE FAMILY BEEN CONTACTED? NO IF YES, WHO AND WHAT WAS THEIR RESPONSE TO THE DEATH? HOW DO PARENTS OR OTHER FAMILY MEMBERS DESCRIBE THE DECEDENT? THE SCENE IF EVENT OCCURRED IN A RESIDENCE, DESCRIBE THE SURROUNDING COMMUNITY: DOES THE RESIDENCE EXHIBIT: FOUL ODORS RODENT OR INSECT INFESTATION SAFETY HAZARDS ( SUCH AS EXPOSED ELECTRICAL CORDS, ETC) ARE THERE ANY SIGNS OF DRUGS OR ALCOHOL USE IN THE RESIDENCE? NO IF YES EXPLAIN: IF TOYS, FURNITURE, PLAYGROUND EQUIPMENT, ETC., IS INVOLVED, DESCRIBE AND
PHOTOGRAPH: WHAT ARTICLES ARE COLLECTED AS EVIDENCE AND WHERE ARE THEY? DO THE ARTICLES HAVE OBVIOUS BLOOD OR TISSUE PRESENT ON THEM? MEDICAL HISTORY HOSPITAL(S)/CLINIC(S) WHERE DECEDENT HAS BEEN SEEN: NAME: CITY: NAME: CITY: OTHER TREATING PHYSICIAN(S): TEL# WAS THIS CHILD THE RESULT OF A PLANNED PREGNANCY? NO YES UNK DID MOTHER OF THE CHILD HAVE ROUTINE PRENATAL CARE DURING HER PREGNANCY? NO YES UNK WERE THERE ANY PROBLEMS OR UNUSUAL EVENTS DURING THE PREGNANCY? NO IF YES, EXPLAIN: BIRTH WEIGHT OF CHILD? HAS THE CHILD'S GROWTH AND DEVELOPMENT BEEN NORMAL SINCE BIRTH? YES IF NO, EXPLAIN: WERE HOSPITALS CHECKED TO SEE IF THEY HAVE RECORDS OF TREATMENT FOR TRAUMA OF
ANY OF THE CHILDREN? DESCRIBE PHYSICIAN'S GENERAL OBSERVATIONS ABOUT THE CHILD: IS THERE A SOCIAL/CASEWORKER INVOLVED? AGENCY: SOCIAL WORKER/CASE WORKER: TEL# AGENCY NOTIFIED OF DEATH BY: INFORMATION GATHERED FROM SOCIAL OR CASE WORKER INCLUDING PREVIOUS RESPONSES TO RESIDENCE: HAVE THE POLICE EVER BEEN DISPATCHED TO FAMILY (AT ANY GIVEN RESIDENCE) FOR ANY
REASON WHATSOEVER? NAME OF INVESTIGATOR DMI# FAMILY STRUCTURE ARE NATURAL PARENTS: TOGETHER SEPARATED DIVORCED WIDOWED MOTHER: DOB: MAIDEN NAME (ALIASES ): FATHER: DOB: ALIAS(ES ): WAS CHILD LIVING WITH: MOTHER FATHER OTHER: IF CHILD WAS LIVING WITH ONE PARENT, WAS THAT PARENT LIVING WITH A SIGNIFICANT
OTHER? NO IF YES, NAME: DOB: SIGNIFICANT OTHER'S MAIDEN NAME (ALIASES) IF APPLICABLE: IF LEGAL GUARDIAN: NAME: DOB: LEGAL RELATIONSHIP: IS EITHER PARENT ROUTINELY ABSENT (EXPLAIN)? WHO IS PRIMARY CARETAKER IF PARENT WORKS (NAME/ADDRESS/TELEPHONE# & RELATIONSHIP TO DECEDENT)? NAMES OF OTHER ADULT RELATIVES OR ACQUAINTANCES LIVING IN OR VISITING THE
HOUSEHOLD AND THEIR RELATIONSHIP TO PARENTS OR DECEDENT: ARE ANY CAREGIVERS ON MEDICATION – EXPLAIN: SIBLINGS (AGE & SEX): ARE ALL OF THE LIVEBORN CHILDREN OF THESE PARENTS STILL LIVING? YES NO (EXPLAIN INCLUDING DATES, ETC.) IF NOT LIVING IN HOUSE, WHERE? WHAT IS THE APPARENT PHYSICAL/EMOTIONAL STATUS OF OTHER CHILDREN? DESCRIBE CLOTHING OF PARENTS AND OTHER LIVE CHILDREN IN RELATION TO CLOTHING OF
THE DECEDENT: DESCRIBE THE APPARENT DEGREE OF CARE PROVIDED FOR LIVE CHILDREN: DESCRIBE THE OTHER CHILDREN'S REACTION TO THE DEATH: HAS THE FAMILY STRUCTURE CHANGED SINCE THE BIRTH OF THE CHILD? HAVE THE CARETAKERS LIVED IN OTHER AREAS OF THE STATE OR COUNTRY (WHERE & WHEN -
FROM MOST RECENT BACKWARD)?