Page 242 - ประมวลสรุปความรู้เกี่ยวกับพิธีสารอิสตันบูลและพิธีสารมินนิโซตา

ISTANBUL PROTOCOL ANNEXES

I. Case information

The following guidelines are based on the Istanbul Protocol. They are not intended to be a fixed prescription, but should
be applied taking into account the purpose of the evaluation and after an assessment of available resources. Evaluation of
physical and psychological evidence of torture and ill-treatment may be conducted by one or more clinicians, depending
on their qualifications.

Date of exam: ....................................................................... Case or report No.: ..............................................................

Exam requested by (name/position): .......................................................................................................................................

Subject’s ID No: .....................................................................................................................................................................

Duration of evaluation (hours/minutes): .................................................................................................................................

Subject’s given name: ..............................................................................................................................................................

Subject’s family name: ............................................................................................................................................................

Birth date: ............................................................................ Birth place: ..........................................................................

Gender: male female other

Reason for exam: ...................................................................................................................................................................

Clinician’s name: ....................................................................................................................................................................

Interpreter: yes no name .............................................................................................................................................

Informed consent: yes no If no informed consent, why?: ...........................................................................................

Subject accompanied by (name/position): ................................................................................................................................

Persons present during exam (name/position): .........................................................................................................................

Subject restrained during exam: yes no If “yes”, how/why? ........................................................................................

Clinical report transferred to (name/position/ID No.): ............................................................................................................

Transfer date: ........................................................................ Transfer time: ......................................................................

Clinical evaluation/investigation conducted without restriction (for subjects in custody) yes no

Provide details of any restrictions: ..........................................................................................................................................

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