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Drunkenness Certificate

FMT drunkenness certificate performa

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Anas Chaudhary
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2K views3 pages

Drunkenness Certificate

FMT drunkenness certificate performa

Uploaded by

Anas Chaudhary
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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Mu 10. a 12, DRUNKENNESS CERTIFICATE No. Name: Age’ Sex Address: Brought by: Consent: Whether the person is under arrest: Hospital No. Yes/No If yes, date & time of arrest (as mentioned in the requisition): Date & time of examination Identification marks: i) ii) Brief history: (os statesby a Alcohol related: rive cf tive, vary ime of consumption consumed wit Ben i ous or accompanied person (pect name ad elton) th food gorgling with mouth wash et) b. Mediéaliiness related: (medeelcondtion smuicting crntennes) General examination: Built Height: Pulse: Orientation: ‘Smell of alcohol from mouth’ ‘smell of alcohol from breath State of clothing: Nourishment: Weight: BP: ‘Temperature: 35 h._ Speech: i Byes 13, Examination for muscular Co-ordination a. Finger nose test b,_ Finger to finger test: ©. Picking a pencil from the floor: 4, Gait (walking on a straight line): fe. Reaction time: 14, Romberg's test: 15. Injuries: 16, Systemic examination: avs: ens: 17. Collection of materials for analysis: FINAL OPINION: From abbve examination, | am of the opinion that: |) Therélisnothing to suggest that the person has consumed alcohol i) The person has consumed alcohol buts not under the influence of alcohol )) The person has consumed alcohol and is under the influence of alcohol. Place: Signature of doctor: Date: Name, designation, Reg. No.’ 36 w FORMAT FOR SENDING BLOOD AND URINE FOR ALCOHOL ESTIMATION i Hospital to be sent to FSL/RFSL in suspected case of drunkenness, the blood and urine samples have qualitative and quantitative analysis in the following format. To, ‘The Deputy Director, ‘The Regional Forensic Science Laboratory, (place) timation of alcohol ~ ree sub’ chemical analysis of blood and urine for qualitative and quantitsiv® © Ref: i) Name, sex, age: ii) MLCNo., date: ii) Crime No., Police station: ‘Samples preserved: 1. Blood: tom venous blood preserved with 400 me Sodium Fluoride + 30 mg Potassium Oxalate” ate and time of collection: EES am/pm. 2. Urine: 1° sample: 30 mlurine collected on (date) at eve enesennns@/PM. (date) at am/pm. 2° sample: 30m! urine collected 0” « sw crystals of Trymol / ml Conc. HCl preservative! For 10 ml urine: Fes gr te sob ott 0510005 the patent wos eH for examination and ano initio exominotin) Place: Signature of the Doctor Name, designation, Reg. No. {The gray copped Vacutainer tube contoins Sodium Fluoride ¢ Potassium Oxalate ( a7 ther colected ofter 30 min of

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