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ctical advice for writing medical certificates in the event of sexual violence
Medical certificate for a child
I, the undersigned, ................................................... (fam ily nam e, first nam e), doctor of medicine,
certify that I have examined on this the ............................ (hour, d ay , m onth, y ear), at the
request of ................................................................ (father, m other, legal representative), the child
....................................... (fam ily nam e, first nam e), born on the .......................... (d ay , m onth, y ear),
living at ...............................................................................................................................................
................................................................... (precise ad d ress of the parents or resid ence of the child ).
During the interview, the child told me:
“ .................................................................................................................................................................. ”
(quote as faithfully as possible the word s of the child without interpreting them )
During the interview, ................................. (nam e of the person accom pany ing the child ) stated:
“ .................................................................................................................................................................. ”
This child presents the following clinical signs:
– On general examination: ......................................................................................................................
((d escribe the behaviour: prostrated , ex cited , calm , frightened , m ute, tearful, etc.)
– On somatic examination: ......................................................................................................................
(d escribe precisely all lesions observed on the entire bod y : signs of abrasion, cuts, scratches,
bites, strangulation, swelling, burns etc. Ind icate th e site, th e ex tent, th e num ber, th e
character (old or recent), the severity etc.)
– On genital examination: .......................................................................................................................
(is the hy m en intact or not (if not, d id it occur recently or in the past), traum atic lesions,
genital infection etc.)
– On anal examination: ...........................................................................................................................
(d etectable traum atic lesions etc.)
– Examinations completed (particularly sam ples taken): ..................................................................
– Evaluate the risk of pregnancy: ..........................................................................................................
In conclusion, this child shows (or does not show) signs of recent violence and an emotional
response (in)compatible with the violence of which (s)he reports to have been victim.
(R em em ber: the absence of lesions d oes not allow a conclusion th at th ere was no sex ual
violence).
Total Temporary Incapacity (TTI) should be granted for .......... days without consideration of
possible complications.
Sequelae may persist leaving a Partial Permanent Incapacity (PPI) to be assessed by an
expert at a future date.
This document is established with the consent of ............................................. (father, m other or
legal representative) and may be used for legal purpose.
Signature of physician
324
Medical certificate for a child
I, the undersigned, ................................................... (fam ily nam e, first nam e), doctor of medicine,
certify that I have examined on this the ............................ (hour, d ay , m onth, y ear), at the
request of ................................................................ (father, m other, legal representative), the child
....................................... (fam ily nam e, first nam e), born on the .......................... (d ay , m onth, y ear),
living at ...............................................................................................................................................
................................................................... (precise ad d ress of the parents or resid ence of the child ).
During the interview, the child told me:
“ .................................................................................................................................................................. ”
(quote as faithfully as possible the word s of the child without interpreting them )
During the interview, ................................. (nam e of the person accom pany ing the child ) stated:
“ .................................................................................................................................................................. ”
This child presents the following clinical signs:
– On general examination: ......................................................................................................................
((d escribe the behaviour: prostrated , ex cited , calm , frightened , m ute, tearful, etc.)
– On somatic examination: ......................................................................................................................
(d escribe precisely all lesions observed on the entire bod y : signs of abrasion, cuts, scratches,
bites, strangulation, swelling, burns etc. Ind icate th e site, th e ex tent, th e num ber, th e
character (old or recent), the severity etc.)
– On genital examination: .......................................................................................................................
(is the hy m en intact or not (if not, d id it occur recently or in the past), traum atic lesions,
genital infection etc.)
– On anal examination: ...........................................................................................................................
(d etectable traum atic lesions etc.)
– Examinations completed (particularly sam ples taken): ..................................................................
– Evaluate the risk of pregnancy: ..........................................................................................................
In conclusion, this child shows (or does not show) signs of recent violence and an emotional
response (in)compatible with the violence of which (s)he reports to have been victim.
(R em em ber: the absence of lesions d oes not allow a conclusion th at th ere was no sex ual
violence).
Total Temporary Incapacity (TTI) should be granted for .......... days without consideration of
possible complications.
Sequelae may persist leaving a Partial Permanent Incapacity (PPI) to be assessed by an
expert at a future date.
This document is established with the consent of ............................................. (father, m other or
legal representative) and may be used for legal purpose.
Signature of physician
324
