ORIGINAL

ACCIDENT REGISTER – CUM – WOUND CERTIFICATE

1. Serial No……………………. 2. Date and time of examination…………….…………………

3. Name………………………………………………………..Age :…….years. Sex : male/female
4. Address………………….…………………………………………………………………………
…………..…………………………………………………………………………………………
5. Identification marks: (1)………………….……………………………………………………….
(2)……………………………………..……………………………………
6. Brought by (Name & address)…………………………………..……………….………………...
7. Requisition (if any) from…………………….…………………………………………………….
8. History and alleged cause of injury………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
9. History was stated by the injured / ……………………………………………………………..**
10.Details of injuries:

11. Findings of physical examination :……………………………………………………………..

………………………………………………………………………………………………………
………………………………………………………………………………………………………
12. Number of additional sheets if any………….
13. Whether admitted or not: Admitted/Observation/Out patient/Expired in casualty/Referred.**
14. Opinion: Could be / could not be as alleged.** Injuries appeared Fresh / Old.

Signature :…………………………………..……
Date :…………………….. Name :……………………..…………………
Place :…………………….. Designation:………………….…………………...
Name of Institution :……………………………………………………………………………………………
** Strike off which is not applicable.
Issued to ……………………………………………………………….. as per his request No. ……….dated …………………….
Date :………………….. Signature of the issuing officer :
2