Medical Examination - Drug Overdose

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DRUG OVERDOSE - ILLICIT & LICIT DRUGS
NAME OF DECEDENT:
This form is to be completed in addition to the ROD form in these guidelines
ILLICIT DRUGS
ARE DRUGS PRESENT?
IF YES, DESCRIBE:
ARE PARAPHERNALIA FOR PREPARATION OR USE OF THESE DRUGS PRESENT?
IF YES, DESCRIBE IT, AND TELL WHAT IS TO BE DONE WITH IT:
WHAT IS THE PRIMARY DRUG OR DRUG COMBINATION (COCAINE/HEROIN) USED BY THE
DECEDENT?
WHAT IS THE INTERVAL BETWEEN THE LAST DRUG ADMINISTRATION AND DEATH?
HOW WERE DRUGS ADMINISTERED:
ORALLY
THROUGH THE NOSE
INJECTED
OTHER:
IF INJECTED, IS THERE EVIDENCE OF TRACK MARKS (CHECK TATTOOS)? ANY INJECTION SITES
NOTED ON AC OR BETWEEN FINGERS OR TOES?
WERE ANY ARTIFACTUAL INJECTION SITES CREATED BY RESCUE PERSONNEL?
IF YES, (CIRCLE THOSE CREATED BY RESCUE AND) DESCRIBE:
IS THERE ANY INDICATION THE DRUG(S) WERE INJECTED INTO THE DECEDENT BY SOMEONE
ELSE?
(IF PARAPHERNALIA IS FOUND ON THE DECEDENT, IT SHOULD ACCOMPANY THE BODY TO OMI. IF
FOUND IN THE SCENE, CONSULT THE CENTRAL OFFICE.)
(IF TAKEN ORALLY OR THROUGH THE NOSE, DETERMINE BEST METHOD FOR PROTECTION/ COLLECTION. IF TRACE EVIDENCE IS FOUND ON THE HANDS OR IN A CONTAINER, COLLECT APPROPRIATELY OR TAKE A SAMPLE FROM THE CONTAINER FOR TESTING - CHECK WITH CENTRAL OFFICE FOR PROPER COLLECTION TECHNIQUES.)
(IF QUANTITIES OF ILLICIT DRUGS ARE LOCATED ON THE DECEDENT, A SMALL SAMPLE SHOULD BE COLLECTED FOR TOX PURPOSES AND SUBMITTED. CHECK WITH THE CENTRAL OFFICE FOR PRO PER COLLECTION/PACKAGING.)
LICIT DRUGS
ARE MEDICATIONS PRESENT?
IF YES, WHERE ARE THE MEDICATIONS LOCATED?
ARE MEDICATIONS PRESENT WHICH W ERE PRESCRIBED TO OTHER THAN THE DECEDENT?
ARE MEDICATIONS OF THE SAME TYPE PRESCRIBED BY MORE THAN ONE PHYSICIAN?
IS THERE ANY EVIDENCE THAT THE MEDICATIONS HAVE BEEN STOCKPILED?
HOW ARE MEDICATIONS ADMINISTERED:
BY DECEDENT
BY OTHERS
IF BY OTHERS, INDICATE WHO AND THEIR RELATION TO THE DECEDENT:
HOW ACCESSIBLE WERE MEDICATIONS TO THE DECEDENT?
DOES THE DECEDENT HAVE A HISTORY OF OVERMEDICATING?
DOES THE DECEDENT HAVE A HISTORY OF PHYSICAL OR MENTAL IMPAIRMENT WHICH WOULD
PRECLUDE HIM/HER FROM ADMINISTERING MEDICATIONS PROPERLY?
(ALL MEDICATIONS ARE TO BE DOCUMENTED APPROPRIATELY INCLUDING ANY TRACE EVIDENCE
COLLECTED FROM THE SCENE OR FROM THE BODY.)
NAME OF INVESTIGATOR
DMI#