THE NATIONAL POLICE SERVICE
MEDICAL EXAMINATION REPORT (P3)
(The issuance and completion of this form is free of charge)
This form is to be completed by a police officer and a trained medical practitioner
(Public officers); electronically or manually in CLEAR and LEGJBLE handwriting
and signed on every page; please complete three copies. Additional page may be
used, stapled and every page signed by the medical practitioner and the police
officer.
PART ONE - DETAILS OF COMPLAINT/INCIDENT (Completed by the police officer
requesting the forensic medical examination)
NATURE OF ALLEGED OFFENCE/INCIDENT __________
DATE AND TIME OF ALLEGED OFFENCE/INCIDENT________
DATE AND TIME REPORTED TO POLICE ___________
DATE OF ISSUE OF POLICE MEDICAL REPORTFORM. _______
POLICE OCCURRENCE BOOK NUMBER --------�FR�O=M=:
POLICE STATION _________________
SERVICE NO AND NAME OF INVESTIGATING OFFICER_SIGNATURE_ TO:
NAME OF MEDICAL FACILITY_______________
REQUEST FOR FORENSIC MEDICAL EXAMINATION OF:
COMPLAINANT SUSPECT/ACCUSED
NAME________________________
AGE. _____ SEX. ___ ID No./Birth Certificate No..___DATE
SENT TO MEDICAL FACILITY________ESCORTED
TO MEDICAL FACILITY BY (fill as applicable):
I .Police Officer Name and Service No .._____Signature __.
Accompanying Authorized Guardian Name ID No.__
(In the "Escorted By" section to the medical/forensic facility fill in the Name of Police
Officer and/ or Authorised Guardian)
BRIEF DETAILS OF THE ALLEGED OFFENCE/INCIDENT
1
PURPOSE OF EXAMINATION (eg. to conduct a forensic examination for suspected
defilement/physical assault/torture)
OFFICER COMMANDING STATION/WARD COMMANDER:
NAME:____________ SIGNATURE: ______
PART TWO - DETAILS OF THE FORENSIC MEDICAL EXAMINATION (to be
completed by the medical practitioner)
MEDICAL/FORENSIC FACILITY REFERENCFJ FILE
NUMBER SECTION
A. DETAILS OF PRACTITIONER AND FACILITY
PRACTITIONER NAMES MEDICALJFORENSIC FACILITY NAME
PRACTITIONER REGISTRATION PATIENT RECORD/FILFJREFERENCE
NUMBER NUMBER
PRACTITIONER QUALIFICATIONS FACILITY TELEPHONE CONTACT
PRACTITIONER TELEPHONE FACILITY PHYSICAL ADDRESS
CONTACT
SECTION B. PATIENT INFORMATION
CONSENT/ASSENT FOR FULL FORENSIC MEDICAL EXAMINATION
I understand that this examination will include:
Full Medical History and a Complete Forensic Medical Examination
Collection of Forensic specimens and/or Medical samples
Taking of notes, photographs, videos, digital images for recording and evidential
purposes including second opinions from forensic/medical experts and peer reviews
I have been informed that any sensitive photographs, videos, and or digital images will
be stored securely and only be made available to other non-medical persons on the order
of a Court.
2
I understand and agree that copy of the medical notes/statement/report and expert
testimony may be given to professionals involved in the case and may be used in court.
I agree to the use of anonymized photographs/imaging/videos for teaching and research
purposes.
I have been advised that I may stop the examination at any point.
CONSENT GIVEN
DATE OF BIRTH_!_!_ AGE:.___ SEX : M F Intersex
PATIENT ACCOMPANIED BY (Insert Name and Relationship)
____________________PERSONS
PRESENT DURING EXAMINATION:
1. ----------------------------
2. ----------------------------
PART 3: SECTION A: RELEVANT MEDICAL HISTORY
(Note any notable disabilities/impairments; document relevant medical history. Include
details relevant to the offence and previous injuries that may affect interpretation of
findings. Additional notes may be attached)
ADDITIONAL MEDICAL HISTORY RELEVANT TO SEXUAL OFFENCES
Since the alleged offence took place has the patient:
CHANGED CLOTHES YES NO UNKNOWN CONDOM
USED YES NO UNKNOWN
BATHED/WASHED/SHOWERED YES NO
URINATED YES NO
DEFECATED YES NO
WIPED YES NO
CURRENTLY PREGNANT YES NO UNKNOWN
CURRENTLY MENSTRUATING YES NO
Nores___________________________
3
History given by:
Name:________ Relationship: _____ Signature_____
SECTION 8: GENERAL EXAMINATION
(All specimens collected must be properly packaged, labelled and preserved. Indicate
relevant clinical signs.)
VITAL SIGNS
Heart Rate_ Respiratory Rate_ Blood Pressure __ Temperature __
Other relevant clinical signs ____________________
STATE OF CLOTHING
Tom/damaged/blood stained/soiled/washed. Indicate if clothes were changed prior to
examination.
Describe the stains/debris (eg. white colored discharge possibly semen)
Clothing Collected For Forensic Analysis YES NO IF NO GIVE REASONS__
Describe the physical appearance and behavior (eg orientation, grooming, coherent,
anxious)
Height'"------ Weight.___ Head Circumference (under 2 yrs)____
. _
General Body Build(frail/normal/obese/other)
Percentiles (Children Only)
Other Relevant Information
Clinical evidence of intoxication (e.g. slurred speech, dilated pupils, ataxia, altered
consciousness etc)
4
SAMPLES COLLECTED FOR TOXICOLOGY WHERE RELEVANT
BLOOD YES NO
URINE YES NO
SECTION C: PHYSICAL EXAMINATION
(Describe the nature, position, shape, extent of injuries on the body. The general
position of all injuries must be denoted on the annexed body charts. Note any
traditional marks/ornaments. Photographs must be documented) Refer to annexes for
labeled diagram of anatomy)
Head and Neck
Oral (note any injuries in the mouth)
Eye/Orbit (Left and Right, including petechiae, peri-orbital edema, intra-orbital /retinal
hemorrhage)
Scalp
ENT (including any injuries within and around the ears)
CNS (level of consciousness - A.V .P.U, Gait, other)
Chest (note any distension, tenderness, abnormality, irregular breathing, cardiac
disorders)
5
Abdomen (note any distension, tenderness, abnormality)
Upper Limbs
Lower Limbs
ESTIMATE AGE OF INJURY(S)
PROBABLE MECHANISM OF INJURY(S)
DEGREE OF INJURY (S): HARM GREVIOUS HARM MAIM (applies only to
Part 3)
DEFINJTIONS: "Harm" Means any bodily hurt, disease or disorder whether permanent
or temporary. "Maim' means the destruction or permanent disabling of any external or
organ, member or sense "Grievous Harm" Means any harm which amounts to maim, or
endangers life, or seriously or permanently injures health, or which is likely so to injure
health, or which extends to permanent disfigurement, or to any permanent, or serious
injury to external or organ.
ADDITIONAL NOTES (INCLUDING PREVIOUS TREATMENT AT OTHER
FACILITIES) CAN BE ATTACHED AND NUMBERED AND SIGNED.
ADDITIONAL NOTES YES NO
TREATMENT/REFERRAL PLAN
6
I conducted the above examination on the _!__!__ and declare that the contents
of this form is true to the best of my knowledge and belief and I am making this
statement knowing that, if it were tendered in evidence, I would be liable to prosecution if
I willfully stated in it anything I knew to be false or which I do not believe to be true.
Name of medical practitioner (full names) -----'Sign ________
PART 4: GENITAL EXAMINATION TO BE COMPLETED IN ALLEGED SEXUAL
OFFENCES AFrER THE COMPLETION OF PART 2 AND 3. (Refer to annexes for
labelled diagram of anatomy)
SECTION A: FEMALE GENITAL EXAMINATION
Tanner Stage (children - refer to annex):
Describe the physical state (anatomy) and any injuries to the genitalia with reference to:
Labia majora:
Labia minora:
Clitoris and peri-urethral area:
Hymen: describe the posterior rim, edges of the hymen, posterior fourchette including
any injuries
Vagina including the opening: ; Indicate speculum use if relevant.
Cervix:
Note and describe any presence of discharge, blood or infection
B: SPECIMEN COLLECTION (3 swabs per sample). Indicate if Evidence kit is used,
include serial No.
MEDICAL SAMPLES
!
Blood
7
Urine YES NO
FORENSIC SEROLOGY SAMPLES
Reference sample - buccal swab blood sample YES NO
Oral Swab (In case of ejaculation) YES NO
Bite mark Swab YES NO
Pubic Hair - specify Combed Shaved Plucked YES NO
Low vaginal swab YES NO
High Vaginal Swab YES NO
Endo-cervical swab YES NO
Anal Swab YES NO
Finger nail clippings/scrapings YES NO
C. MALE GENITAL EXAMINATION
Tanner stage (children - refer to Annex):
Describe in detail the physical state (anatomy) of and injuries to the:
Prepuce/frenulum:
Shaft:
Scrotum:
Anus:
Note presence of discharge from the prepuce, around anus, or/ on thighs, etc; whether
recent or of long standing
D. SPECIMEN COLLECTION (3 swabs per sample. Indicate if Evidence kit is used.
include serial No.)
MEOICJ\L SAMPLES
IBlood
8
Urine YES NO
FORENSIC SEROLOGY SAMPLES
Reference sample - buccal swab blood sample YES NO
Oral swab (In case of ejaculation) YES NO
Bite mark Swab YES NO
Pubic Hair - specify Combed Shaved Plucked YES NO
Anal Swab YES NO
Rectal swab YES NO
Finger nail clippings/scrapings YES NO
E.ADDITIONAL REMARKS/OPINION BY THE PRACTITIONER
F. MEDICATION ADMINISTERED (Note any medication administered prior to or after
examination eg.
PEP,EC,TT,Hep B)
G. RECOMMENDATIONS/REFERRALS (eg urgent need for further medical review,
psychiatric mental status assessment)
AGE ASSESSMENT URGENT PEDIATRIC REVIEW PSYCHOTHERAPY
CHILDREN SERVICE
9
PART 5: CHAIN OF CUSTODY(List the specimens collected)
S/No Evidence/ No.of Evidence/ Evidence/ Date Comments/
.
ltem(s)
,_..... -r----
Items
ltem(s)
Received
ltem(s)
(DD/MM/YY) Remarks
Delivered
From
To
SPECIMENS COLLECTED BYMEDICAL PRACTITIONER
FULL NAME: ______ ON THIS DAY_/__/_AT _._ HOURS
FACILITYSTAMP WITH DATE CLEARLYMARKED ON COLLECTION DATE
SPECIMENS RECEIVED BYPOLICE OFFICER
FULL NAME/SERVICE NO: ___ON THIS DAY_I__I_ AT_._ HOURS
FACILITYSTAMP WITH DATE CLEARLYMARKED ON RECEIVED DATE
I hereby declare that the information provided in this Medical Examination Report is
true and correct to the best of my knowledge and belief. I am aware that if the
information is submitted as evidence and any content given is found to be false or
incorrect, I may be liable for prosecution. I consent to partake of any prescribed oath /
affirmation and consider any such oath/ affirmation as binding on my conscience.
PRACTITIONER SIGNATURE___ POLICE OFFICER SIGNATURE ___
BODYCHART
APPENDIX I: TICK THE APPROPRIATE BOX: CHILD ADULT MALE
FEMALE INTERSEX
10
10
11
11
APPENDlX 2: TANNER STAGE (this does NOT give an age estimate)
{ y } ('y =--=-= I I
'-.. ✓
®
:.._
--=---
;
( T ) -=!a� ('y /) =---•-
j
} -..,_- ('y-) -- �
) -·---- (�T/) =--c:--
� ��
{
�
-
[ \ -� ('q f ·) :- -
APPENDIX 3: GENITALIA
DETAILS OF MALE GENITAL FINDINGS
-
,,..,,.
..........
....,_,_st/lJ'_)
-
T- ,_�_,,..,,.,,,.1/J)
- (- lfS/IIO)
12
12
INTERSEX GENITALIA
Normal F I II III IV V Normal M
�u�u��o���
'-,,
w ✓ ..........
(!)
✓ ......__,
(!)
✓ ........... I"\ ✓
(!)
.....,___Q✓
C:)
---................
Page
...._
DETAILS OF FEMALE GENITAL FINDINGS
...-_
,.. ........ ,,,01�11
POSITION DURING EXAMINATION
--- Supine YES No
-............
Left lateral YES No Knee chest
---------
YES No
C
....._.....,...... Clitoris
- 3 Labia minora
Hymen ' Perineum
----'IQ/fr)
:�Anus
13
13
APPENDIX 4: ORAL CAVITY AND DENTITION
ORAL CAVITY DENTITION
Central Lateral
incisor
Upper lip Superior Canine First
premol11
Gum labial Second
frenulum premolar
Hard palate First molar
Second
Uvula molar Third mola-
Soft palate
Tongue Second Third moi.
Buccal mucosa Frstmolar
(Inner cheek Lingual Second Frst
lining) frenulum premolar premolar
Inferior labial Teeth Canine Lateral
frenulum Central Incisor
inClsOr
Lower lip ('1�.....,
•..,.<ll,¼,t.-... ,p,,,
duct opening
Credit The Respiratory Syatem. Availab� at http1://www.theresplratorysystem.com/gk>ssaryforal-cavity/
CHILO
ADULT R
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
i�i�GV��t�V�V w
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Credit Science Direct.
14
14
