(नियम ७ को उपनियम (२) सँग सम्बन्धित)
घाउ जाँच केस फाराम

मिति र दर्ता नं.
Date & Police case No:
।
घाइतेको नाम, थर, उमेर र लिङ्ग
Name, Age & Sex of Injured Person:-

घाइतेको वतन ः–
Address of Injured Person :

कार्यालयको नाम ठेगाना ः–
Name & Address of the office (Sender):-

घाउ जाँच गराउन लिई जाने प्रहरी कर्मचारीको नाम, दर्जाः–

2.
3.
Type of Injury

अङ्गभङ्ग ………………..
अङ्ग फेरिएको वा छिनालिएको वा फुकालिएको ………………….
पुरानो घाउखत ………………….
अन्य ……………………..
Type of Weapon/Object used:-
Condition of the Patient :
Whether fatal or not? (मर्ने वा नमर्ने)
Remarks
(कैफियत)
घाउजाँच गर्ने अधिकारी ः–
दस्तखतः–
नाम थरः–
दर्जाः–
कार्यालयः–
मितिः–
कार्यालयको छाप ः–
FULL BODY-ANTERIOR AND POSTERIOR VIEWS (VENTRAL AND DORSAL)
GUIDE LINES:-
Nature of Injury:- Mention Abrasion or contusion or lacerated or incised or
stabbed or, gunshot wound, burns or fracture or
dislocation.
Type of Injury :-

अङ्गभङ्ग
१.
२.
३.
४.
५.
६.
अङ्ग फोर्ने वा फुकाईने वा छिनाइने ः–
If there is partial damage such as limping after fracture / dislocation if there is organ
damage such as lungs, liver, heart, kidney, spleen, intestine and brain.

पुरानो घाउखत ः–
Do not include vaccination or operation scars.

अन्य ः

cratch, biting, burns, electric burns, and using vapour and smoke for all injuries
mentioned above indicate under which headlings they come.
Type of the weapon / Object used:- Mention sharp or blunt, heavy or light, gunshot,
Chemicals or fire burns or any other specific characteristics of the weapon / object used.
Condition of the patient:- Mention injury to the vital organs as fatal; multiple
fractures as fatal or any other injuries which with the available medical aid at the place of
examination is likely to cause death.