PROFORMA FOR EXAMINATION OF ALLEGED RAPE CASE (FEMALE)
Requisition from______________________of Police Station _________________
vide his letter No.__________________________Dated_________________
Name (In full) ___________________________________________
Age as assessed____________Sex__________________M.L.C. No._____
Occupation__________________________Address________________________
Date of Examination____________ Time of Examination_____________________
Alleged time of offence _______AM/PM_________________ Married/Unmarried
Brought by____________________________________
Consent for examination – Victim_____________________________________
Guardian _____________________________________
Identification Marks (1)________________________________________
(2) _____________________________________
History/Detailed account of occurrences as given by woman, especially about the following :
a) Date, Time & Place of Occurrence__________________________
b) Exact position of parties_____________________________________
c) Did she struggle or cry for help? ___________________
d) Was she conscious all the time?____________________ _
e) Did she urinate or defecate after the act ?___________________
Pain?____________
f) Date and time of lodging the complaint_________________
Explain delay_________________________
Enclosure 5 (Refers to Para 20 b xii)
Menstrual History:_________________________________________ ______
M.C.___________________________________–Regular/Irregular
L.M.P.______________________________
Age at Menarche_______________________________
Whether bath was taken Yes/No___________________________When_________
Whether clothes are changed. Yes/No____________________________
Any other relevant information :
Physical Examination
General behavior :
Gait
1) Height (cms) _____________________Weight _______________Kgs
2) General build________________________________
3) Condition of teeth (broken etc)___________________________________
4) Abrasions, bite marks etc over the body (Face, Back of Shoulders, Arms and Thighs) ____________________________________________________
5) Breast, Developed/Not Developed________________________________
6) Secondary Sexual characters Fully developed/Not developed.________
7) Examination of clothes: Presence of tears on clothes
Presence of Mud/Blood/Seminal stains.
8) Matting of public Hairs due to semen: Present/Absent
(Public Hairs to be cut & preserved for examination)_________________
9) Presence of Blood or Seminal Stains on the genitals : Present/Absent (Stains to be preserved on saline swabs for examination)________________
10) Examination of Genitals:
Development of Genital organs : Developed/Not Developed____________
Vulva .____________________Vagina______________________
Perineum______________________ Forchette____________________
P/S Examination_______________________________________________
P/V Examination___________________________
11) Swabs for examination:
a) Vaginal swabs
i. Vulval ____________ ii
Low Vaginal____________
iii. High Vaginal_______________________
b) Urethral Smear for Gonococci_____________________
12) Venereal diseases if any, __________________________
13) Blood Group examination if there is bleeding injury___________
14) Nails__________________________
Signature/Thumb impression of person examined.
OPINION:
Date :
Place:
Signature of the Medical Officer
Name Degree
Designation Reg No.
To,
The Police Sub Inspector,
Police Station
NOTE:
a) When the age is disputed, as has to be determined as per proforma for age estimation.
b) Specimen to be Preserved for examination:
1) Public Hairs
2) Blood & Urine
3) Blood Stain
4)Clothes for exam of stains
5) Vaginal smear/Swab
6) Nails
7) Head hair
8) Bite mark swabs.