PROFORMA FOR EXAMINATION OF SEXUAL OFFENCESIALLEGED RAR
EXAMINATION OF THE VICTIM( Rape Servivor)
LPreliminary date
M.L.C. No/ Sexual offences case No
E24.....cime No....uls.3.1.51b
Appearances found on the person of a female calling herself
age
stated....2.3.. .years, an inhabitant of
..kaaedhi. Negat CheAna... .who was sent with letterNo
.....Z0.2I2.of Police Station L9.am.Gthimuvetooi
dated
....2 20 22 from ...... and, tor injuries said to
have been caused on ......))202......as
2 a result of alleged rape.
Identification marks:
1) Mele on eft og nean knae
2) Ngle on aghY chin
The person was first seen by the
undersianed at .......
(hospital)
at. ..J.Q. ...am / pm on .......22..and the examination was commenced
at
J.0.1.3...am Ipm on 12-|-2022
.when the following injuries
etc., were found.
PRELIMINARY PARTICULARS:
1. Name of the individual:
shlpa
2 Parent's or
-Vewlaleh
guardian's name:
3
Address: 24, adhi chemi
4. Occupation : sadet
5 Age as alleged by the victim: 23
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6. Person accompanying or brought by : P.<, twer kodu prho shto
signature of the individual consenting
or her left thumb impression,
In the case of minor, consent of the
quardian and his/her signature or
thumb impression
Name of female attendanttnurse Ns. Rathi
present at the time of examination
and Signature f banpral Madicine
Dep!
AcSM H
HISTORY
1 Age: 23
2 Gravaly: Net applialle
3 Age of menarche:
4. Date of last menses:
5. Whether pregnant: J
6 Most recent coitus prior to alleged assault:
Time: Condom used or not:
Date:
7 Patient's statement, whether she
is a virgin:
8. suffering from any iliness
O
Is she
and taking any medicines:
9. History of any STD
(past or present)
illness:
10. History of Psychiatric
surgical
procedures: if any
11. Previous vaginal
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12 Use of alcohol or drugs within 24 hours
prior to alleged assault. If so
amount and time of ingestion : No
a Date and time when the rape was
said to have been committed
|.1|2022; lo pm
b) Place where it was committed: (at hd
C) Exact cirCumstances under which
the rape was committed. Le.
whether the parties were standing
or lying on the ground
d)
Lying
Whether she was menstruating at the time: O
e) Whether she was sensible during the
whole time the offence was
committed
or under the influence of
)
alcohol or other intoxicant: : Sawible and corlomy
Whether she uttered any cries or was she terified: dGtfor help
9) Did penis penetrate vulva? y
h) Did assailant wear condom? NO
) "Since alleged assaut," has the
victim:
1) Douched ND
(2) Bathed NO (3) Defaecated yes (4) Urinated
yos.
II Physical Examination:
B.P: 25/40 Pulse: 10o p
Temp:32c wt:
Height: 15
2) General appearance:
3) Emotional status : Any'u ndhcyeue
4) Clothing:
a) Blood stains : FGundin inre ga pments
b) Seminal stains: Foudin ihner joen
) Other discharges: Seiva fswnd on
Buton bhom i t l aced fend ord.
) Foreign material: Jeen
Cigauelie buds ud iywic&
4
e) Hairs :
e Body surface (exact anatomical position) :
a) Scratches: Bock nck kvnt
b) Bruises: pireyeyt
c) Lacerations: .
Bla maks ou brcas &
a) Oher injuies:
6) Mouth; u !
7) Fingernails :
Blsod stand.
8) Genitals :
a) Pubic hair, length, matted or no:
b) Vuva: &welen on cenges ted
d) Vagina : Nid
e) Fourchette: 1 n
) Perineum:
g) Cervix : Ni
9) Is STD present: N0
Smears taken from Vagina, cervix, etc.
10)
a) Gram's stain: Pg8itve
pgtV.
spermatozoa :
b) Stain for
findings : Ni
11) Any other
laboratory:
12) Any Material sent to the froo roil
Epifhet
Blscd som ples
Investigations
13) Results of laboratory Negative
Pregnancy test:
a) (-)
Serology : H1V
b)
c) Gonorrhoeal infection elosoned
d) Spermatozoa :
pssitve
phosphatase:
e) Acid
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) Grouping of blood and semen : otve
9) Hair examination : One
Collection of Evidence: - No touch Technique - Clothes and belongings
were collected herself in a private room
in a white peice of paper
1) Blood in two tubes for serology and grouping: Taken
2) Fingernail scrapings :Taken
3 Loose pubic hair: Taken
4) Cut pubic hair: Taken
5) Hair, fibres and blood stains on body and clothing : T leen
6) Vaginal material for evidence of spermatozoa: Taken
(Four slides from veginal material to be
7) Cervical material for gonorrhoea :
8) Vaginal secretion on two cotton swabs: Taken
a) Semen typing : Send to F.S.L
b) Acid Phosphatase Test:
IlI Opinion:
1 On local genital examination evidence of signs of
recent sexual intercourse:
Evidence of penetrative sexual intercouse
Preaent /Absent
Evidence of Non penetrative sexual intercouse
Present /Absent
Evidence of Forceful Vaginell anal intercouse
Present Absent
The individual is used / not used to an act
like that of sexual
intercourse.
Evidence of genital / Physical injuries
Present / Absent
-Evidence of genital/Physical assualt Present / Absent
Place: Acs MCH
Signature of Doçtor
Aun kothk
Date: 12-(1. 20 22 MBBS
Name & Designation
Note: The doctor need not conduct all investigations
materials suggesled. It differs in each case suggested or collect
handied.
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