Verbale di primo sopralluogo per infortunio o incidente domestico
L’anno…..............………...il giorno……………. ......……..del mese di………….........………… alle ore……….....................…………..............…………..............……via………………........................ n. ...................................................................................................................................................

A seguito di richiesta di intervento pervenuta alle ore ......................... da parte del/della Sig./Sig.ra ....................................................................................................................…………..............….………..............…………..............…………..............…………..............…………..............…………...............…………..............…………..............…………..............…………..............…………............…………..............………….............................................................................................................
[specificare modalità di richiesta di intervento, se telefonica o diretta specificandone le circostanze]

nato/a.................................…………..............…………..............…………..............………….......... il..............................…………..............…………..............…………...................…………................
residente a............................…………..............…………..............……………………………………
in..........................................…………..............…………..............…………..............…………........
identificato/a mediante …………………………………………………………………………………… 
n. .....................………….................................................................................................................
rilasciato/a da…..............…………..............…………...............………….............………….............
in data…….........…………..............…………..............…………..............…….…….........................

◻	presente al sopralluogo
◻	non presente al sopralluogo

I sottoscritti Agenti/Ufficiali appartenenti al Comando in intestazione
…………………...............................................................................................................................
.........................................................................................................…………..............…………....
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procedono mediante i seguenti accertamenti:

in seguito all’infortunio/incidente domestico avvenuto in data ……………………………………….
alle ore ............................... nel quale è rimasto infortunato o vittima di incidente domestico, il/la 
Sig./Sig.ra…………………………………………………………………………………………………...
nato/a.................................…………..............…………..............…………..............………….......... il..............................…………..............…………..............…………...................…………................
residente a............................…………..............…………..............……………………………………
in..........................................…………..............…………..............…………..............…………........
identificato/a mediante …………………………………………………………………………………… 
n. .....................………….................................................................................................................
rilasciato/a da…..............…………..............…………...............………….............………….............
in data…….........…………..............…………..............…………..............…….…….........................

Già trasportato/a presso l’Ospedale……………………………………………………………………..
alle ore ............................ …………..del giorno ..............................................................................
oppure
Presente al sopralluogo e rinvenuto/a presso l’abitazione .....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............……….................................................................................................................
..........................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............……….............................................................................................

[specificare accuratamente le circostanze del rinvenimento]
[descrivere attentamente le circostanze in cui è avvenuto l’infortunio/incidente domestico]
.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............………...............................................................................................

[descrivere analiticamente le circostanze di luogo e di fatto – indicando nei minimi particolare lo stato dei locali, gli oggetti presenti, le tracce, gli abiti indossati dalla vittima e specificando tutti gli elementi di interesse investigativo – procedendo con rilievi video/fotografici/planimetrici]
.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............………...............................................................................................

[se refertato/a descrivere attentamente il tipo di lesioni]
.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............………...............................................................................................

[oppure specificare se deceduto/a a seguito dell’infortunio/incidente domestico]
.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............………...............................................................................................

[nel caso di mancata presenza di referto descrivere attentamente il tipo di lesioni]
.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…

Persone informate dei fatti:

Cognome............................................................Nome……….........................................................
nato/a a……………………………………………..............................................................................
il ......................................................................................................................................................
residente a………………………………………………………………………………………………….
in……………………………………………………………………………………………………………..
tel…………………………………………………………………………………………………………….
cell…………………………………………………………………………………………………………… 
identificato/a mediante esibizione di …………………………………………………………………….
n. ....................................................................................................................................................
rilasciato/a da ………………………………………………………………………………………………
il………………………………………………………………………………………………………………
valevole al ………………………………………………………………………………………………….

Cognome............................................................Nome……….........................................................
nato/a a……………………………………………..............................................................................
il ......................................................................................................................................................
residente a………………………………………………………………………………………………….
in……………………………………………………………………………………………………………..
tel…………………………………………………………………………………………………………….
cell…………………………………………………………………………………………………………… 
identificato/a mediante esibizione di …………………………………………………………………….
n. ....................................................................................................................................................
rilasciato/a da ………………………………………………………………………………………………
il………………………………………………………………………………………………………………
valevole al ………………………………………………………………………………………………….

Cognome............................................................Nome……….........................................................
nato/a a……………………………………………..............................................................................
il ......................................................................................................................................................
residente a………………………………………………………………………………………………….
in……………………………………………………………………………………………………………..
tel…………………………………………………………………………………………………………….
cell…………………………………………………………………………………………………………… 
identificato/a mediante esibizione di …………………………………………………………………….
n. ....................................................................................................................................................
rilasciato/a da ………………………………………………………………………………………………
il………………………………………………………………………………………………………………
valevole al ………………………………………………………………………………………………….

L’abitazione risulta di proprietà di:

Cognome............................................................Nome……….........................................................
nato/a a……………………………………………..............................................................................
il ......................................................................................................................................................
residente a………………………………………………………………………………………………….
in……………………………………………………………………………………………………………..
tel…………………………………………………………………………………………………………….
cell…………………………………………………………………………………………………………… 

Cognome............................................................Nome……….........................................................
nato/a a……………………………………………..............................................................................
il ......................................................................................................................................................
residente a………………………………………………………………………………………………….
in……………………………………………………………………………………………………………..
tel…………………………………………………………………………………………………………….
cell…………………………………………………………………………………………………………… 

[specificare in dettaglio circostanze e risultanze nel caso di intervento di personale medico e paramedico del 118, oppure del medico legale]

.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............………...............................................................................................

[specificare altri congiunti provvedimenti adottati con atti a parte: es. sequestri, perquisizioni, ecc.]
.....................…..............…………..............…………..............…………..............…………..............……….......................................................................................................................................................................…..............…………..............…………..............…………..............………….................…………..............…………..............…………..............…………..............…………..............……………..............………...........................................................................................................................................…..............…………..............…………..............…………..............…………................…………..............…………..............…………..............…………..............…………..............…………………………..............………...............................................................................................

Letto, confermato e sottoscritto.

Chiuso alle ore ……..............………....................del .……...................................…………....

	

Gli Agenti/Ufficiali di Polizia Giudiziaria
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Le persone intervenute

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