अनुसूची–१६
(दफा २२ को उपदफा (१) सँग सम्बन्धित)
घाउ जाँच केश फारामको ढाँचा

INJURY EXAMINATION REPORT

(IT IS USED IN CASE OF EXAMINATION OF DETAINEE ALSO)

1. Case Registration No.:
2. Name of the Office referred for injury examination (with letter ref. No. and Date) :
3. Name, Age, Date of birth and Sex of the injured person:
4. Address:
5. Name of the accompanying Police Personnel:
6. Name of the Hospital/Health centre:
7. Date, time and place of examination:
8. Identification mark of the examinee :
9. Consent for examination taken from :

Injured person                       Family member or others

10. Brief history about the incident (how and when the injuries were produced?):

11. Medical history of the examinee :

12. General Physique and vitals :

Height:       Weight:              Pulse:         B.P.:                    B.P:

Temperature:                                             Respiratory Rate:

Temperature:                         Respiratory Rate:

Degree of Consciousness:

13. Injuries (Name, Size, Site, Color, Surrounding area, Signs of treatment, Bleeding Marks, Sign of Healings, any Imprints and content etc.) :

A. Type of injury

a. Simple:

b. Angabhanga (Grievous) :

c. Severe:

d. Other remarks:

B. Type of weapon/object used:

(i) Blunt force              (ii) Sharpe force
(iii) Pointed objects     (iv)Projectile                     (v) Heat
(vi) Chemical                   (vii) Others  (Specify)

C. Condition of the patient at the time of examination :

D. Severity (Explain the severity  in terms  of  existing condition and possible  complication) :

E. Investigation and reports (for example X-ray, USG, Blood, Urine etc) :

F. Treatment provided (briefly) :

G. Referral (Where and Why?):

H. Follow up (if necessary ) :

I. Re- Examination (Whether case needs information about grade of disability ) :

Opinion: (Condition of examinee, severity of the injury, age of the injury and possible causative objects should be considered to frame opinion)

Name of the Examiner:              Signature:

Qualification:-                            MC ⁄ NHPC Reg. No. :

Office/Hospital/Health Centre: Date:

Seal of the Hospital/Health Centre:

द्रष्टव्यः

• घाउ जाँच कार्यसम्भव भएसम्म Forensic विषयको विशेषज्ञले र त्यस्तो विशेषज्ञ नभएमा तालिम प्राप्त चिकित्साकर्मीले गर्नु पर्नेछ ।
•  घाउ जाँच गर्ने विशेषज्ञ वा चिकित्साकर्मीले नै प्रतिवेदन तयार गर्नु पर्नेछ ।
• सम्भव भएसम्म कम्युटर टाइप गरी प्रतिवेदन तयार गर्नु पर्नेछ, सो नभएमा स्पष्ट बुझिने गरी उल्लेख गर्नु पर्नेछ । साथै परीक्षण प्रतिवेदनको सक्कल प्रति नै संलग्न गर्नु पर्नेछ ।
•  निर्धारित स्थानमा विवरण उल्लेख गर्न नपुग भएमा छुट्टै पानामा समेत विवरण उल्लेख गर्नु पर्नेछ ।