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National Guidelines on Management of Sexual Violence in Kenya

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Annex 3: P3 Form<br />

Annex 3<br />

P3 Form<br />

This P3 Form is free <strong>of</strong> charge<br />

THE KENYA POLICE P3<br />

MEDICAL EXAMINATION REPORT<br />

PART 1-(To be completed by the Police Officer Request<strong>in</strong>g Exam<strong>in</strong>ati<strong>on</strong>)<br />

From_____________________________________Ref____________________________________<br />

_________________________________________Date___________________________________<br />

To the___________________________________________________________Hospital/Dispensary<br />

I have to request the favour <strong>of</strong> your exam<strong>in</strong>ati<strong>on</strong> <strong>of</strong>:-<br />

Name__________________________________Age__________(If known)<br />

Address________________________________________________________________________.<br />

Date and time <strong>of</strong> the alleged <strong>of</strong>fence__________________________________________________<br />

Sent to you/Hospital <strong>on</strong> the__________________20__________<br />

Under escort <strong>of</strong>___________________________________________________________________<br />

and <strong>of</strong> your furnish<strong>in</strong>g me with a report <strong>of</strong> the nature and extent <strong>of</strong> bodily <strong>in</strong>jury susta<strong>in</strong>ed by him/her.<br />

Date and time report to police________________________________________________________<br />

Brief details <strong>of</strong> the alleged <strong>of</strong>fence<br />

_________________________________________________________________________________<br />

_________________________________________________________________________________<br />

_________________________________________________________________________________<br />

_________________________________________________________________________________<br />

Name <strong>of</strong> Officer Command<strong>in</strong>g Stati<strong>on</strong><br />

Signature <strong>of</strong> the Officer Command<strong>in</strong>g Stati<strong>on</strong><br />

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