3 minutes to complete
The Forensic Examination Request Form is available to law enforcement agencies and victim service providers.
Case Number:
Victim's Name:
Victim's Date of Birth:
Victim's Gender:
Assault Location:
Date of Assault:
Time of Assault:
Description of Assault:
Description of Injuries:
Requested Forensic Examination:
Examiner's Name:
Examiner's Qualifications:
Examiner's Address:
Examiner's Phone Number:
Examiner's Email Address: