More examples in Healthcare/Medical Examination Reports
Railroad Incident Medical Examination Example
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VEHICLE WAS HEADED IN WHAT DIRECTION? WHERE DID THE VEHICLE LAND AFTER THE IMPACT? HOW FAR WAS VEHICLE FROM THE POINT OF IMPACT? IF THE DECEDENT WAS EJECTED, WHERE AND HOW FAR FROM THE POINT OF IMPACT WAS
DECEDENT LOCATED? ARE INJURIES ON THE DECEDENT CONSISTENT WITH INJURIES FROM THE IMPACT? PASSENGER OF TRAIN DID PASSENGER JUMP OR FALL FROM TRAIN? WAS THIS A WITNESSED INCIDENT (AND IF SO, IS HISTORY CONSISTENT)? WHAT SAFETY RULES IF ANY WERE VIOLATED? WHERE WAS THE DECEDENT GOING TO AND COMING FROM? WAS THIS A WITNESSED "COLLAPSE"? RAILROAD ACCIDENT INVOLVING DERAILMENT: DESCRIBE THE ACCIDENT (ANSWER AS MANY OF THE
QUESTIONS AS APPLY ABOVE) - IT IS IMPORTANT TO TRY TO DETERMINE THE POSSIBLE DRUG OR
ALCOHOL INVOLVEMENT OF RAILROAD EMPLOYEES TO DETERMINE IF THIS WAS A FACTOR IN THE
INCIDENT.
(ALL RAILROAD DEATHS MUST BE REPORTED TO THE FEDERAL RAILROAD ADMINISTRATION -
ESPECIALLY WHEN THOSE DEATHS INVOLVE RAILROAD EMPLOYEES.) NAME OF INVESTIGATOR DMI# RAILROAD NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines THE SCENE DESCRIBE THE SCENE GENERALLY: HOW WAS ACCESS GAINED TO WHERE DECEDENT WAS FOUND? DESCRIBE NUMBER OF TRACK AND DIRECTION IN WHICH THEY RUN? RAILROAD TRAFFIC CONDITIONS AT TIME OF INCIDENT: MOTOR VEHICLE TRAFFIC CONDITIONS AT TIME OF INCIDENT (IF APPLICABLE): PEDESTRIAN TRAFFIC CONDITIONS AT TIME OF INCIDENT (IF APPLICABLE): WHAT TYPE OF AREA DID INCIDENT HAPPEN IN (RESIDENTIAL, RURAL, BUSINESS, WAREHOUSES, ETC.)? IS AREA WHERE INCIDENT OCCURRED KNOWN FOR OTHER ACCIDENTS/INJURIES? RAILROAD CROSSING DESCRIBE THE CROSSING (MOTOR VEHICLE, PEDESTRIAN, ETC.): SIGNALS PRESENT AND OPERATIONAL? GATE PRESENT AND OPERATIONAL? IF NOT A REGULAR CROSSING, WHAT IS DISTANCE TO NEAREST CROSSING AND WHAT KIND OF
CROSSING IS IT? ARE OTHER SAFEGUARDS PRESENT, AND WERE THEY DETERMINED TO BE DEFECTIVE IN ANY
WAY? WOULD SAFEGUARDS HAVE PREVENTED THE INCIDENT? IS THE AREA SECURED (FENCED) IN ANY WAY? THE TRAIN HOW IS THE TRAIN IDENTIFIED? IN WHAT DIRECTION WAS TRAIN HEADED? WHAT WAS ESTIMATED OR ACTUAL SPEED OF TRAIN AT TIME OF INCIDENT? INFORMATION PROVIDED BY: DID TRAIN STOP AT SCENE OF INCIDENT? IF YES, HOW FAR DID IT TRAVEL AFTER IMPACT? IF
NOT, WHERE WAS IT LOCATED? HOW MANY CARS WAS TRAIN PULLING AT TIME OF INCIDENT? DESCRIBE ANY TRACE EVIDENCE RECOVERED FROM THE UNDERCARRIAGE OR THE
COWCATCHER IF APPLICABLE: WHAT DAMAGE WAS DONE TO THE TRAIN? PEDESTRIAN STRUCK BY TRAIN WAS THE INCIDENT WITNESSED, AND WHAT IS RELEVANT HISTORY? IS SCENE CONSISTENT WITH HISTORY? IF NOT, EXPLAIN DISCREPANCIES: WHERE WAS DECEDENT WHEN STRUCK (BETWEEN TRACKS, TO THE SIDE, ETC.)? WAS DECEDENT: STANDING SITTING LYING OTHER: UNK WHERE: WAS DECEDENT CROSSING: WALKING RUNNING UNK (DIRECTION): FROM TO IF LYING ON THE TRACKS WAS DECEDENT BETWEEN THE RAILS OR WAS DECEDENT LAYING
ACROSS THE RAILS (DESCRIBE)? HOW FAR FROM THE POINT OF IMPACT WAS DECEDENT ORIGINALLY FOUND? FT NUMBER OF CARS WHICH PRESUMABLE RAN OVER: ARE INJURIES ON THE DECEDENT CONSISTENT WITH INJURIES FROM IMPACT? DRIVER OR PASSENGER OF MOTOR VEHICLE STRUCK BY TRAIN WAS THE DECEDENT THE DRIVER OR PASSENGER OF MV (AND HOW WAS THIS INFORMATION
ACQUIRED)? WAS LAW ENFORCEMENT ABLE TO ESTIMATE THE SPEED OF THE VEHICLE? MPH WERE SEATBELTS USED? WAS VEHICLE SITTING ON THE TRACK? WHAT SIDE OF THE VEHICLE DID THE TRAIN IMPACT?
DECEDENT LOCATED? ARE INJURIES ON THE DECEDENT CONSISTENT WITH INJURIES FROM THE IMPACT? PASSENGER OF TRAIN DID PASSENGER JUMP OR FALL FROM TRAIN? WAS THIS A WITNESSED INCIDENT (AND IF SO, IS HISTORY CONSISTENT)? WHAT SAFETY RULES IF ANY WERE VIOLATED? WHERE WAS THE DECEDENT GOING TO AND COMING FROM? WAS THIS A WITNESSED "COLLAPSE"? RAILROAD ACCIDENT INVOLVING DERAILMENT: DESCRIBE THE ACCIDENT (ANSWER AS MANY OF THE
QUESTIONS AS APPLY ABOVE) - IT IS IMPORTANT TO TRY TO DETERMINE THE POSSIBLE DRUG OR
ALCOHOL INVOLVEMENT OF RAILROAD EMPLOYEES TO DETERMINE IF THIS WAS A FACTOR IN THE
INCIDENT.
(ALL RAILROAD DEATHS MUST BE REPORTED TO THE FEDERAL RAILROAD ADMINISTRATION -
ESPECIALLY WHEN THOSE DEATHS INVOLVE RAILROAD EMPLOYEES.) NAME OF INVESTIGATOR DMI# RAILROAD NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines THE SCENE DESCRIBE THE SCENE GENERALLY: HOW WAS ACCESS GAINED TO WHERE DECEDENT WAS FOUND? DESCRIBE NUMBER OF TRACK AND DIRECTION IN WHICH THEY RUN? RAILROAD TRAFFIC CONDITIONS AT TIME OF INCIDENT: MOTOR VEHICLE TRAFFIC CONDITIONS AT TIME OF INCIDENT (IF APPLICABLE): PEDESTRIAN TRAFFIC CONDITIONS AT TIME OF INCIDENT (IF APPLICABLE): WHAT TYPE OF AREA DID INCIDENT HAPPEN IN (RESIDENTIAL, RURAL, BUSINESS, WAREHOUSES, ETC.)? IS AREA WHERE INCIDENT OCCURRED KNOWN FOR OTHER ACCIDENTS/INJURIES? RAILROAD CROSSING DESCRIBE THE CROSSING (MOTOR VEHICLE, PEDESTRIAN, ETC.): SIGNALS PRESENT AND OPERATIONAL? GATE PRESENT AND OPERATIONAL? IF NOT A REGULAR CROSSING, WHAT IS DISTANCE TO NEAREST CROSSING AND WHAT KIND OF
CROSSING IS IT? ARE OTHER SAFEGUARDS PRESENT, AND WERE THEY DETERMINED TO BE DEFECTIVE IN ANY
WAY? WOULD SAFEGUARDS HAVE PREVENTED THE INCIDENT? IS THE AREA SECURED (FENCED) IN ANY WAY? THE TRAIN HOW IS THE TRAIN IDENTIFIED? IN WHAT DIRECTION WAS TRAIN HEADED? WHAT WAS ESTIMATED OR ACTUAL SPEED OF TRAIN AT TIME OF INCIDENT? INFORMATION PROVIDED BY: DID TRAIN STOP AT SCENE OF INCIDENT? IF YES, HOW FAR DID IT TRAVEL AFTER IMPACT? IF
NOT, WHERE WAS IT LOCATED? HOW MANY CARS WAS TRAIN PULLING AT TIME OF INCIDENT? DESCRIBE ANY TRACE EVIDENCE RECOVERED FROM THE UNDERCARRIAGE OR THE
COWCATCHER IF APPLICABLE: WHAT DAMAGE WAS DONE TO THE TRAIN? PEDESTRIAN STRUCK BY TRAIN WAS THE INCIDENT WITNESSED, AND WHAT IS RELEVANT HISTORY? IS SCENE CONSISTENT WITH HISTORY? IF NOT, EXPLAIN DISCREPANCIES: WHERE WAS DECEDENT WHEN STRUCK (BETWEEN TRACKS, TO THE SIDE, ETC.)? WAS DECEDENT: STANDING SITTING LYING OTHER: UNK WHERE: WAS DECEDENT CROSSING: WALKING RUNNING UNK (DIRECTION): FROM TO IF LYING ON THE TRACKS WAS DECEDENT BETWEEN THE RAILS OR WAS DECEDENT LAYING
ACROSS THE RAILS (DESCRIBE)? HOW FAR FROM THE POINT OF IMPACT WAS DECEDENT ORIGINALLY FOUND? FT NUMBER OF CARS WHICH PRESUMABLE RAN OVER: ARE INJURIES ON THE DECEDENT CONSISTENT WITH INJURIES FROM IMPACT? DRIVER OR PASSENGER OF MOTOR VEHICLE STRUCK BY TRAIN WAS THE DECEDENT THE DRIVER OR PASSENGER OF MV (AND HOW WAS THIS INFORMATION
ACQUIRED)? WAS LAW ENFORCEMENT ABLE TO ESTIMATE THE SPEED OF THE VEHICLE? MPH WERE SEATBELTS USED? WAS VEHICLE SITTING ON THE TRACK? WHAT SIDE OF THE VEHICLE DID THE TRAIN IMPACT?