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Get CA Cal EMA 2-920 2009-2021

CALIFORNIA EMERGENCY MANAGEMENT AGENCY SUSPICIOUS INJURY REPORT Cal EMA 2-920 4/1/09 STATE OF CALIFORNIA INFORMATION DISCLOSURE This form is for law enforcement use only and is confidential in accordance with Section 11163. 2 of the Penal Code. This form shall not be disclosed except by local law enforcement agencies to those involved in the investigation of the report or the enforcement of a criminal law implicated by this report. In no case shall the person identified as a suspect be allowed access to the injured person s whereabouts. The person making this report shall not be required to disclose his/her identity to their employer PC 11160. Part A PATIENT WITH SUSPICIOUS INJURY 1. PATIENT S NAME Last First Middle 2. BIRTH DATE 3. GENDER M 5. PATIENT S RESIDING ADDRESS Number and Street / Apt NO P. O. Box City State 6. PATIENT SPEAKS ENGLISH Y 4. SAFE PHONE NUMBER F Zip 7. DATE AND TIME OF INJURY N Identify language spoken 8. LOCATION / ADDRESS WHERE INJURY OCCURRED IF AVAILABLE Date Time am pm Unknown Check here if unknown 9. PATIENT S COMMENTS ABOUT THE INCIDENT Include any identifying information about the person the patient alleges caused ADDITIONAL PAGES ATTACHED the injury and the names of any persons who may know about the incident. 10. NAME OF SUSPECT If identified by the patient 11. RELATIONSHIP TO PATIENT IF ANY 12. SUSPICIOUS INJURY DESCRIPTION Include a brief description of physical findings and the final diagnosis. Part B REQUIRED AGENCIES RECEIVING PHONE AND WRITTEN REPORTS 13. LAW ENFORCEMENT AGENCY NOTIFIED BY PHONE Mandated by PC 11160 14. DATE AND TIME REPORTED 15. NAME OF PERSON RECEIVING PHONE REPORT First and Last 16. JOB TITLE 17. PHONE NUMBER 19. AGENCY INCIDENT NUMBER Part C PERSON FILING REPORT 20. EMPLOYER S NAME 22. EMPLOYER S ADDRESS Number and Street 23. 2 of the Penal Code. This form shall not be disclosed except by local law enforcement agencies to those involved in the investigation of the report or the enforcement of a criminal law implicated by this report. In no case shall the person identified as a suspect be allowed access to the injured person s whereabouts. In no case shall the person identified as a suspect be allowed access to the injured person s whereabouts. The person making this report shall not be required to disclose his/her identity to their employer PC 11160. The person making this report shall not be required to disclose his/her identity to their employer PC 11160. Part A PATIENT WITH SUSPICIOUS INJURY 1. PATIENT S NAME Last First Middle 2. BIRTH DATE 3. GENDER M 5. Part A PATIENT WITH SUSPICIOUS INJURY 1. PATIENT S NAME Last First Middle 2. BIRTH DATE 3. GENDER M 5. PATIENT S RESIDING ADDRESS Number and Street / Apt NO P. O. Box City State 6. PATIENT SPEAKS ENGLISH Y 4. PATIENT S RESIDING ADDRESS Number and Street / Apt NO P. O. Box City State 6. PATIENT SPEAKS ENGLISH Y 4. SAFE PHONE NUMBER F Zip 7. DATE AND TIME OF INJURY N Identify language spoken 8. LOCATION / ADDRESS WHERE INJURY OCCURRED IF AVAILABLE Date Time am pm Unknown Check here if unknown 9. .

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