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 D....
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How to fill out the CA Cal EMA 2-920 online
Filling out the CA Cal EMA 2-920 form correctly is crucial for effective reporting of suspicious injuries. This guide will walk you through each section of the form in a clear and supportive manner to ensure accurate completion.
Follow the steps to complete the form accurately.
- Click the ‘Get Form’ button to acquire the CA Cal EMA 2-920 form and open it in your editing tool.
- In Part A, enter the patient’s name in the fields provided, including the last name, first name, and middle name as applicable.
- Fill in the patient’s birth date to accurately reflect their age.
- Indicate the patient’s gender by selecting the appropriate option.
- Provide the patient’s residing address, ensuring to avoid using a P.O. Box.
- Record the patient’s safe phone number for contact purposes.
- Select if the patient speaks English. If not, identify another language spoken.
- Fill in the date and time of the injury. If unknown, be sure to check the appropriate box.
- Describe the location or address where the injury took place, if available.
- Document any comments the patient has about the incident, including information about any alleged suspects.
- If the patient identifies a suspect, include their name in the designated section.
- Outline the relationship between the patient and the suspect, if applicable.
- Provide a brief description of the suspicious injury, including physical findings and any diagnosis.
- In Part B, record the law enforcement agency that was notified by phone, following the mandated requirements.
- Enter the date and time the report was made to the agency.
- Include the name of the person who received the phone report along with their job title.
- Fill in the contact number for the law enforcement agency.
- Enter the agency receiving the written report as mandated.
- Document the agency incident number associated with the report.
- In Part C, provide the employer’s name and contact number.
- Include the employer’s address in the provided fields.
- List the name of the health practitioner completing the report.
- State the job title of the health practitioner.
- Have the health practitioner sign the form in the designated area.
- Finally, fill in the date the form was signed.
- Once all sections are complete, save changes, and then download, print, or share the completed form as needed.
Complete the CA Cal EMA 2-920 form online today to ensure proper reporting of suspicious injuries.
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