VII. Annex 2 Annex 2. Case Details Form Case Details: Case No. / UR No. ............................................. Place of examination...................................................... Subject’s name ..................................................... ................................................................................. Address............................................................... Address ...................................................................... ......................................................................... ................................................................................. Age ….… D.O.B. ……/……/…..… M / F........... Tel................................ Fax ........................................ E-mail ......................................................................... Consent: Obtained from ........................................................................................................................... Time called .............................. hrs Time of arrival........................... hrs Time of departure ………… hrs (original call-out) …… / …… / …… at scene ……. / …….. / …… from scene …… / …… / …… Time of commencement............... hrs Time of completion.................... hrs Time of completion ……… hrs of examination …… / …… / …… of examination …… / …… / …… of notes …… / …… / …… Observers: Name …………………………. …………………………. …………………………. Status Name Status …………………..... …………………….. …………………….. …………………..... …………………….. …………………….. …………………..... …………………….. …………………….. Circumstances / History: Clothing: (a) From patient....................................................... ........................................................................ ........................................................................... ........................................................................ ........................................................................... ........................................................................ ........................................................................... ........................................................................ (b) From others (police, ambulance, family, friends, others) Jewellery: Name of informant ................................................. ........................................................................ ........................................................................... ........................................................................ ........................................................................... ........................................................................ ........................................................................... ........................................................................ Specimens: Specimens handed to: ..................................... ................................. ..................................... ................................. Status................................................................... ..................................... ................................. 82 The Minnesota Protocol on the Investigation of Potentially Unlawful Death (2016) Recipient name....................................................... Recipient signature.................................................. Time ……. hrs Date ……… / ……… / …………