Fall

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FALLS
NAME OF DECEDENT:
This form is to be completed in addition to the ROD form in these guidelines
GENERAL QUESTIONS FOR ALL "FALLS"
FROM WHAT HEIGHT IS DECEDENT ALLEGED TO HAVE FALLEN?
IS THE DECEDENT FAMILIAR WITH THE TERRAIN?
WAS THE FALL WITNESSED, AND IF SO BY WHOM AND UNDER WHAT CIRCUMSTANCES?
FALL FROM HEIGHT - (MOUNTAIN, CLIFF, PARACHUTIST, HANG-GLIDER, ETC.)
WHAT WAS THE NATURE OF THE JUMP/FALL?
WHAT KIND OF BACKGROUND/EXPERIENCE (PROFESSIONAL/RECREATIONAL) DOES THE
DECEDENT HAVE FOR THE ACTIVITY PERFORMED?
WAS SAFETY EQUIPMENT BEING USED?
IF YES, EXPLAIN:
DID ANYONE DETERMINE THAT THE EQUIPMENT WAS DEFECTIVE?
IF YES, WHO MADE THE DETERMINATION AND WHAT DID THEY FIND?
WHO PACKED THE DECEDENT'S PARACHUTE, AND WHAT IS THEIR RELATIONSHIP TO THE
DECEDENT? (THE PARACHUTE MUST BE SECURED SO THAT IT CAN BE EXAMINED BY AN EXPERT.)
FALL FROM HEIGHT - (ANIMAL, BICYCLE , STEPS, LADDER, BED, ETC.)
HOW DID FALL OCCUR?
HAVE THE BICYCLE, STEPS, LADDER, BED, ETC., BEEN EXAMINED TO DETERMINE WHETHER THEY
WERE CONTRIBUTORY TO THE FALL (UNSAFE STEPS, ICE ON STEPS, BROKEN LADDER, ETC.)?
IF YES, BY WHOM, AND WHAT WAS DETERMINED?
WERE SAFEGUARDS AVAILABLE?
IF YES, DESCRIBE:
DID ANYONE EXAMINE THE SAFEGUARDS TO DETERMINE IF THEY ARE DEFECTIVE IN ANY WAY?
IF YES, WHO EXAMINED AND WHAT WAS DETERMINED?
WAS DECEDENT FAMILIAR WITH THE EQUIPMENT BEING USED?
IF DECEDENT FELL FROM AN ANIMAL, WHAT KIND OF ANIMAL IS IT?
WHY WAS THE DECEDENT ON THE ANIMAL?
WHAT EXPERIENCE IF ANY DID THE DECEDENT HAVE WITH ANIMALS OF THIS KIND?
IF SADDLE, EQUIPMENT, OR OTHER SAFETY GEAR IS INVOLVED, DESCRIBE:
FALL FROM SAME HEIGHT - (FALL WHILE WALKING OR STANDING)
WHAT ACTIVITY WAS THE DECEDENT INVOLVED IN PRIOR TO THE FALL?
WAS DECEDENT FAMILIAR WITH THE AREA?
DID THE DECEDENT FALL:
FORWARD
BACKWARDS
SIDEWAYS
WAS THIS A STANDING FALL, OR DID DECEDENT GO ONTO HIS/HER KNEES BEFORE COLLAPSING?
DID THE DECEDENT'S HEAD STRIKE ANY HARD OBJECT?
IS THERE ANY INDICATION THAT OBJECTS IN THE AREA (ROCKS, FURNITURE, ETC.)
CONTRIBUTED TO THE FALL IN ANY WAY?
HOSPITAL DEATH - AFTER A FALL
WHAT WAS THE ADMITTING DIAGNOSIS:
IF DEATH OCCURRED WHILE IN THE HOSPITAL, HOW WAS IT DETERMINED THAT THE DEATH
WAS CAUSED BY THE FALL OR THAT THE FALL WAS CONTRIBUTORY?
WERE LABS RUN TO DETERMINE ADMISSION BA
DRUGS:
OTHER?
IF FALL CAUSED FRACTURES, WAS THE DECEDENT IMMOBILIZED PRIOR TO DEATH?
IF YES, FOR HOW LONG, AND IS THERE ANY SUSPICION OR CONFIRMATION OF A
PULMONARY EMBOLUS?
WAS SURGERY PERFORMED TO REPAIR THE FRACTURE?
IF YES, INDICATE WHERE, DATE, AND TYPE OF SURGERY:
IF THE DECEDENT SUFFERED HEAD INJURIES, HOW WERE THEY DIAGNOSED AND WHAT WAS THE
COURSE OF TREATMENT?
WAS DECEDENT CONSCIOUS OR COMATOSE THROUGHOUT HOSPITALIZATION?
WAS THE DECEDENT ON A DNR STATUS?
NAME OF INVESTIGATOR
DMI#