More examples in Healthcare/Medical Examination Reports
Medical Examination for Fire Example
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Text in this example:
FIRE NAME OF DECEDENT: This form is to be completed in addition to the ROD form in these guidelines FIRE VICTIM HISTORY OF PLAYING WITH MATCHES, BUILDING FIRES, OR SMOKING IN BED? HISTORY OF OTHER FAMILY MEMBERS WITH TOBACCO/ALCOHOL OR MATCH/FIRE STARTING
HISTORIES? DID FIRE CONSUME THE IMMEDIATE AREA WHERE THE DECEDENT WAS FOUND? IF CARBON MONOXIDE LEVEL WAS RUN LOCALLY WHAT WERE RESULTS: % STRUCTURE RESIDENCE SINGLE FAMILY MULTI-FAMILY TRAILER AUTO PUBLIC BUILDING MOTEL HOTEL BARN GARAGE WAREHOUSE BRICK STONE CONCRETE FRAME METAL OTHER: IF THIS IS A STORAGE FACILITY, WHAT IS STORED IN THE BUILDING? EXITS AVAILABLE (DESCRIBE IF PLAINLY MARKED AND HOW THEY ARE MARKED): SMOKE DETECTORS AT SCENE (DESCRIBE): FIRE EXTINGUISHERS AT SCENE (DESCRIBE): FIRE ALARM INSTALLED (DESCRIBE): FIRE DETECTION EQUIPMENT OPERABLE? YES NO UNKNOWN TYPE OF FIRE DAM AGE: SMOKE BURN SMOKE & BURN TYPE OF FIRE: ELECTRICAL SOLVENT NATURAL GAS WOOD AND FURNISHINGS OTHER: HOW DID FIRE START (DESCRIBE)? WHERE DID FIRE START? IS THERE ANY SUSPICION OF ARSON (IF SO, EXPLAIN)? EVIDENCE FOUND AT THE SCENE: SMOKING MATERIALS ALCOHOL CONTAINERS MEDICINES NARCOTICS OTHER PARAPHERNALIA:
(IT IS IMPORTANT THAT ALL PARAPHERNALIA AC COMPANY THE REMAINS FOR ID PURPOSES - THAT INCLUDES ALL
SUSPECTED HUMAN REMAINS, ARTICLES OF JEWELRY, DENTURES, CLOTHING, ETC. IN, ON AND SURROUNDING
THE BODY -THIS IS ESPECIALLY TRUE OF BODIES FOUND IN AUTOMOBILES - A THOROUGH SEARCH MUST BE MADE
OF THE SCENE.) NAME OF INVESTIGATOR DMI#
HISTORIES? DID FIRE CONSUME THE IMMEDIATE AREA WHERE THE DECEDENT WAS FOUND? IF CARBON MONOXIDE LEVEL WAS RUN LOCALLY WHAT WERE RESULTS: % STRUCTURE RESIDENCE SINGLE FAMILY MULTI-FAMILY TRAILER AUTO PUBLIC BUILDING MOTEL HOTEL BARN GARAGE WAREHOUSE BRICK STONE CONCRETE FRAME METAL OTHER: IF THIS IS A STORAGE FACILITY, WHAT IS STORED IN THE BUILDING? EXITS AVAILABLE (DESCRIBE IF PLAINLY MARKED AND HOW THEY ARE MARKED): SMOKE DETECTORS AT SCENE (DESCRIBE): FIRE EXTINGUISHERS AT SCENE (DESCRIBE): FIRE ALARM INSTALLED (DESCRIBE): FIRE DETECTION EQUIPMENT OPERABLE? YES NO UNKNOWN TYPE OF FIRE DAM AGE: SMOKE BURN SMOKE & BURN TYPE OF FIRE: ELECTRICAL SOLVENT NATURAL GAS WOOD AND FURNISHINGS OTHER: HOW DID FIRE START (DESCRIBE)? WHERE DID FIRE START? IS THERE ANY SUSPICION OF ARSON (IF SO, EXPLAIN)? EVIDENCE FOUND AT THE SCENE: SMOKING MATERIALS ALCOHOL CONTAINERS MEDICINES NARCOTICS OTHER PARAPHERNALIA:
(IT IS IMPORTANT THAT ALL PARAPHERNALIA AC COMPANY THE REMAINS FOR ID PURPOSES - THAT INCLUDES ALL
SUSPECTED HUMAN REMAINS, ARTICLES OF JEWELRY, DENTURES, CLOTHING, ETC. IN, ON AND SURROUNDING
THE BODY -THIS IS ESPECIALLY TRUE OF BODIES FOUND IN AUTOMOBILES - A THOROUGH SEARCH MUST BE MADE
OF THE SCENE.) NAME OF INVESTIGATOR DMI#