CD JSON Generator

SCAN TEAM MEMBERS INCHARGE

Jkm Social Worker-In-Charge

Name

Telephone No

Investigation Officer

Name

Police Report No

Telephone No

School Counsellor

Name

Name Of School

Telephone No

Medical Social Worker In Charge

Name

Telephone No

HISTORY

Date Of Incident(S)

Time Of Incident(S)

Location Of Incident

Suspected Perpetrator

Nature Of Incidents(S)

Other Relevant History

Social/Family History

Medical History

PHYSICAL EXAMINATION

General and Systemic Examination

Genitalia Examination

Diagrammatic Findings

Photographs Taken

YesNo

DIAGNOSIS

Diagnosis

MANAGEMENT

Specimens (Tick only specimens taken)

Chemistry Department

Others, specify

Pathology Lab

Others, specify

Management of Rape within 72 hours

Contraception: T. Levonogestrol 1.5mg stat

HIV Prophylaxis: T. Combivir (Zidovudine 300mg/Lamivudine 150mg) BD for 4/52

Antibiotic:

Plan

Orders

Referral

Outgoing Referrals

Comments

SIGNATURES