Reporting Instrument

Reporting Instrument The Mississippi State Medical Examiner’s Office has developed the following reporting instrument with respect to the collection of forensic samples pursuant to Miss. Code Ann. § 97-5- 51. This form is to be used in conjunction with the collection of fetal tissue when a pregnancy termination is performed on a minor who is less than fourteen (14) years of age at the time of the pregnancy termination procedure or with the collection of cord blood when a minor who is under the age of sixteen (16) gives birth to an infant and if it would be reasonable to assume that the minor’s pregnancy resulted from a sex crime against a minor. Source: Miss. Code Ann. §§ 45-1-3, 97-5-51 Name (minor): ______________________________________________ Address (minor): _____________________________________________ Name (guardian/caretaker): ____________________________________ Address (guardian/caretaker): __________________________________ Please check one (1) of the following conditions necessary to complete this form: The mother of the infant will not identify the father of the infant The mother of the infant lists the father of the infant as “Unknown” The person the mother of the infant identifies as the father of the infant disputes his fatherhood The person the mother of the infant identifies as the father of the infant is twenty-one (21) years of age or older The person the mother of the infant identifies as the father of the infant is deceased Additional information: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Signature ___________________________ Printed Name ________________________