THE EFFECTIVENESS OF USING TOOTHBRUSH OR TONGUE DEPRESSOR

IN ORAL CARE OF PATIENTS WITH NASOGASTRIC TUBE

A RESEARCH PAPER PRESENTED TO

Dr. Belinda Buenafe

In Partial Fulfillment of the Requirements for the Course of

Nursing Research

Encina, Clarisse Anne

Figueroa, Kriselda
Francisco, Charmaine
Galang, Alyssa Marie
Kimpo, Clairisse Ann
Macatuggal, Marie Louise
Magnaye, Armisti Rizzane
Manalo, Erilyn Leigh
Manao, Demil Isaac
Marciales, Kristel Rose Diane
Maret, Jimalyn
Nicolas, Mark Angelo

MARCH 2012

CHAPTER I
INTRODUCTION
Oral hygiene is the condition or practice of maintaining the tissues and
the structure of the mouth. Oral hygiene includes brushing of the tongue and
teeth to remove food particles and residue, bacteria, and plaque; massaging
the gums with toothbrush, dental floss, or water irrigator to stimulate
circulation and foreign matter, and cleansing dentures and ensuring their
proper fit to prevent irritation (Mosbys Dictionary, 2007).
Elderly patients especially those who are unconscious, should be
provided nutrition through another route other than oral. The commonly used
artificial feeding for this patient is through NGT (Nasogastric tube).
According to a study conducted by Dr. Leibovitz (2007), the lack of
mechanical clearance of the mouth through chewing and swallowing puts
NGT-fed patients at risk for acquiring GNB (Gram-Negative Bacteria) such as
Pseudomonas aeruginosa, aside for the fact that this bacteria can adhere to
plastic tubes like the one used in NGT.
At times like this, oral hygiene is a critical part of preventing the
acquisition of such opportunistic microorganisms, not only that it contributes
on the health, well-being, and comfort of the patient (Cape, 2007).

But most often oral care which is a part of the basic activity of living is
widely neglected and oftentimes results to short-term complications such as
Pneumonia and long term effects such as dental decay (Woodrow, 2006)
The Surgeons general report on Oral Health in America (2000) noted
that poor oral hygiene puts elderly patients susceptible to general systemic
health problems like cardiovascular diseases, poor nutrition, and respiratory
infections.
Ventilator Associated Pneumonia (VAP) is among other infections
usually acquired during ones stay in the hospital. It is considered as the
leading cause of disease prevalence and death cases in the Intensive Care
Units (ICU) of hospitals (Bercault and Boulain, 2001).
Ganz (2008) claims that nurses could directly affect the decrease in the
incidence of VAP through effective oral care. Based on her study, nurses of
different units practice oral care in many different techniques using different
products and they have n uniform methods of oral assessments. She
believes that the variability in following different techniques may be due to
different in training and the culture aspects of different country. She also
stated that AACCN produced a practice alert which recommends the use of
current evidenced-based oral care technique in the care of critically ill which
includes of the use of toothbrush and chlorhexidine gluconate as the
solution.

Ames (2011), argues that toothbrush could contribute to patients risks

to bacterial contamination due to potential mucosal and gingival tissue
breakdown, bacteria could have a full contact with the patients blood stream
which increases the risk for infection.
Aside from the issue about the method used in oral care, considering
the solution used, storage of equipment used in oral care also plays an
important role in increasing or decreasing the number of colonies of
microorganism in the oral cavity.
Berrya (et.al 2011), suggests that he use of individual storage
containers is important in minimizing the risk of contamination between oral
hygiene tools and other general hygiene objects such as shaving items,
combs, etc.
All related studies conducted abroad recommend the use of
toothbrush in the oral care of patients. But in the Philippines, especially in
government hospitals, it was observed that the commonly used tool for oral
care is tongue depressor. There is no significant study which was conducted
in the Philippines which can explain the common practice in the hospital
settings, or recommend a standard procedure for oral care. Most often, oral
care practices in the government hospitals in the Philippines still depend on
the preference of the patient and his family. Oral hygiene had been a low
priority due to the small number of nurses working in this institution. So
instead, the family decides on the patients oral care practice, not aware of

its importance and effect on the patients health. These are the reasons why
the researchers decided to conduct a study regarding oral care.

Purpose of the Study

The purpose of the study to evaluate the effect of using toothbrush or
tongue depressor in oral care on the status of the mouth, and number of
colonies and types of microorganisms present in the oral cavity of elderly
patients with nasogastric tube.

Research Questions
1. Using the oral assessment tool, what is the status of the mouth of:
a) Experimental Group (tongue depressor)
b) Control group (toothbrush)
2. How many colonies of microorganisms are present in the oral cavity before
and after intervention?
a) Experimental Group (tongue depressor)
b) Control group (toothbrush)
3. What are the types of microorganisms are present in the oral cavity before
and after intervention?

a) Experimental Group (tongue depressor)

b) Control group (toothbrush)

4. Is there any significant difference in the type of microorganisms found in

the oral cavity before and after intervention?
a) Experimental Group (tongue depressor)
b) Control group (toothbrush)

5. Is there any significant difference in the number of colonies of

microorganisms found in the oral cavity before and after intervention?
a) Experimental Group (tongue depressor)
b) Control group (toothbrush)

Significance of the Study

The researchers firmly believe that study would be relevant and serve
as a good help in the following:
Patients
This study will primarily help the patients in alleviating the discomfort
they feel because of nasogastric tube inserted to them. This study will also
help in the recovery of the patient since this is a hygiene practice that
enables to reduce the number of microorganisms in their oral cavity.

Nurses
As nurses, they play a vital role in promoting care and comfort to their
clients. With this study, they will acquire new knowledge about oral care and
enhance their skills in caring with clients. Furthermore, this study would
greatly help and enable them to discover the more efficient and safe
technique to be used on nasogastric clients for oral care in order to promote
good oral health maintenance while saving more time, energy and perform
more tasks.
Hospital Administrators
This study will be a big help to the hospital if one of the equipment is
better in performing oral care to the elderly patients with nasogastric tube.
The one that will be proven more effective can be used as a standard
operating procedure in the hospital.
Nursing Education
Institutions involved in the education of nurses and other allied health
professionals would benefit from this study because they would be able to
make use of the research data in the improvement of their educational
standards when it comes to teaching oral care and practices among
students.
Student nurses

This study will give students an early innovation in oral care practices
that can be used in their related learning experiences in the hospitals. This
will also provide information of what the best method to be use in oral care
when they become nurses in the future.
Family members
This study would enable them to learn a certain method or technique
to be used with their family member as a tool for oral care and would know
the important points to remember in order to accomplish the technique
easily and in a safe away. This study would also help them recognize some
effects or consequences of poor oral health care.
Future Researchers
This study will enable them to understand further the techniques or
methods used in elderly patients with nasogastric tube for oral care. They
will also be able to use this study in the future for comparison with other
studies and as a reference material as well.

SCOPE AND LIMITATIONS

The study is limited to the comparison of the effect of oral care using
toothbrush or tongue depressor. The study includes the assessment of the
status of the mouth using an oral assessment tool adapted from Singapore,
counting

of

the

number

of

colonies

and

identifying

the

type

of

microorganisms present in the oral cavity of conscious elderly patients with

NGT. To accomplish this, the researchers will do oral care to the population
sample. Assessment of the status of the mouth and collection of sample from
the oral mucosa will be done before and after the oral care intervention. The
sample collected will undergo bacterial cultivation. These cultures will be
inoculated in nutrient agar plate and incubated at 37 oC to 40oC for 24-72
hours. The results will then be observed and analyzed. The researchers will
also consider other factors that may affect the result of the study such as
time of intervention and sample collection, and type of solution to be used.

CHAPTER II
THEORETICAL FRAMEWORK
This chapter presents different related literature and studies which
provide information on oral care of patients with NGT. All of these have a
relationship to the present study.

It is logically appropriate to go through

some related literature and studies and to analyze the available resources
that could be utilized most effectively.
This literature review supplements background information related to
oral care of patients with NGT.

Review of Related Literature and Studies

COLONIES OF MICROORGANISMS
Oral microorganisms can include fungal, protozoal, and viral species. A
variety of organisms in the microenvironment of the oral cavity adhere to the
teeth, the gingival sulcus, the tongue, and the buccal mucosa. Each site has
a unique way of allowing the organisms to establish their residency. The
normal flora in healthy individuals maintains similar patterns. When local or
systemic disease process or concomitant use of medications alters this
overall pattern, atypical organisms begin to predominate and some normal

microorganisms with a benign nature, such as Candida Albicans, become

pathogenic. (Najjar and Elston, 2010)
Microorganisms grow readily in ICU patients mouth (Intensive care
Nursing: A Framework for Practice 2nd Ed.). It is because the mouth is warm,
moist and static; saliva accumulates at the back of the throats, especially if
gag/swallowing reflexes are impaired; blood and plaque provides protein for
bacterial growth (OReilly, 2003); normal flora is often destroyed by
antibiotics; immunosuppressant facilitates growth.
Similar to Leibovitz (2003) studies, Gomes (2003) showed that the
presence of a nasogastric feeding tube is associated with colonization of
pathogenic organisms particularly Gram-negative bacteria. However, Gomes
considered oral or dental disease, antibiotic therapy; systemic illness or
malnutrition and reduction of salivary flow are responsible for colonization of
Gram-negative bacteria in oral and pharyngeal flora in nasogastric-tube-fed
patients. Also, the use of a nasogastric feeding tube and administration of
food increase gastric pH and lead to colonization of gastric secretions. It has
also been suggested that gastric bacteria could migrate upward along the
tube and colonize pharynx.
On the same year, Leibovitz conducted a similar study. The study
concluded that a higher rate of isolation of pathogenic found in patients on
nasogastric feeding than those on oral feeding. Pseudomonas aeruginosa
and Klebisella pneumonia was cultured in the nasogastric patients.

Another study of Leibovitz (2005) identified Staphylococcus aereus and

various

GNB

in

oral

cavity

of

patients

with

nasogastric

tube.

semiquantitative culture was used to measure the bacterial load for each
bacterial group by counting the number of bacterial colonies on each plate.
The following grading was used for each of the study organisms: 0, no
growth; 1, up to 10 colonies; 2, 10 up to 20 colonies, and 3, more than 20
colonies. The mean bacterial load was calculated as the mean of the scores
accorded for the colonies count of each patient.

ELDERLY PATIENT
Aside from that, oropharynx of NGT-fed elderly patients may provide
such an ecosystem and promote the colonization of P. Aeruginosa. This
colonization could be due to several factors such as the papillary structure of
the dorsum of the tongue, the lack of mastication and swallowing
(eliminating
P.Aeruginosa,

their
a

mechanical
well-known

cleansing

effect),

biofilm-producing

and

the

tube

microorganism

itself.

may

be

exploiting the NGT to create a thriving habitat, (Leibovitz, 2003)

One of the most important factors of infection is host susceptibility;
where in normal aging may predispose elders to increased risk of infection
and delayed healing. Anatomical and physiological agents that are protective
when a person is younger often change in structure and function with
increasing age and then provide a decrease in their protective ability. (Kozier,
2007)

ORAL CAVITY
The oral cavity has been already considered as a potential reservoir for
pathogenic microorganisms for a long time. This site of the body has hard
non-shedding surfaces for microbial colonization, which allows accumulation
of extracellular products and formation of some biofilms that may serve as
culture media for bacteria and contribute to the development of anti-biotic
resistance. Ecologic condition within the mouth may vary and change the
ecosystem, facilitating the growth of pathogenic organisms. (Leibovitz, 2003)

TOOTHBRUSH
According to Vex (2010), Older adults may need to use electric
toothbrushes and other special brushes to clean between teeth. People with
arthritis or other limitations to movement may need modified toothbrushes
with thicker handles. Dryness of the mouth with age, our salivary glands
may naturally produce less saliva leading to dryness of the mouth. More
often, the cause may be the medicines we take (for example for high blood
pressure or depression). Dryness of the mouth can cause discomfort with
dentures, bad breath and tooth decay. Older adults may see an increase in
tooth decay due to reduced saliva. Saliva helps to wash away the acids
produced by bacteria in plaque - acids that attack the tooth structure and
cause decay. Adults may also be prone to decay because of exposed root

surfaces or worn-out chewing surfaces where the protective layer of hard

enamel has been lost. Decay on these surfaces can spread rapidly.
Toothbrushing may allow bacteria to enter the bloodstream, especially
in patients with poor dental health (Ames, 2011).

TONGUE DEPRESSOR
According to DeKeyser, Ganz et., al.(2008), the most commonly used
supplies in oral care were gauze pads followed by tongue depressors and
toothbrushes. Often nurses attach gauze pads to a tongue depressor to use
for oral care -a practice that substitutes for the use of sponges or swabs
attached to a stick.
Components of Colgate toothpaste and tongue depressor
There are several components of Colgate toothpaste and Plax.
According to Gardner (2011), Colgate toothpaste contains Triclosan which
kills a variety of bacteria and provides 12-hour protection.
Akande (2004) compared the efficacy of three mouth rinse: (1)
Macleans,

(2)

Colgate

Plax,

and

(3)

Listerine.

Macleans

contain

cetylprinidium chloride which was proven more effective in inhibiting

microbial growth than Colgate Plax, which contains Phenolic compounds, and
Listerine, which contains Triclosan (the same anti-microbial compound as
Colgate toothpaste). The study stated that the mean microbial count
reduction of the groups which used Colgate Plax and Listerine are not
statistically significant.

Synthesis
With the previous research, it was stressed that oral cavity is a good
reservoir for microbial growth, especially to persons who are deprived of the
normal function such as mastication and swallowing. Such conditions are
common to unconscious patients fed through NGT. Cases associated with
these conditions are those of elderly patients suffering from disabilities such
as CVAs situated in ICUs and are mechanically ventilated. Due to their
disability, these patients cannot perform oral care by themselves, which is a
basic activity of daily living. With factors such as oral cavity, being a good
reservoir, inability to perform oral hygiene, decreased mastication, and the
presence of NGT, these patients are at risk for infection.
This study aims to evaluate the effect of toothbrush and tongue
depressor in the status of the mouth and, the number of colonies and type of
microorganisms present in the oral cavity. It differs from the previous studies
conducted in the sense that it focuses on the use of toothbrush and tongue
depressor with a commonly used toothpaste and mouth rinse of the same
brand. There is limited number of studies conducted abroad. Aside from that,
previous researchers did not compare the effect between toothbrush and
tongue

depressor.

They

focused

more

on

the

identification

of

the

microorganism while this study focuses not only in identifying the type but
also the number of colonies of microorganisms present in the oral cavity, and
the status of the mouth. Lastly, there is no study conducted in the Philippines

regarding the importance of oral care which draws interest from the
researchers with oral care given low priority.

Conceptual Framework
INDEPENDENT VARIABLE

DEPENDENT

VARIABLE

METHODS
IN ORAL
CARE
>Tongue
Depressor
>Toothbrush

>Number of
colonies of
microorganism
Experimental Group

O2
Controlled Group

O2

O1

O1

> Type of
microorganism
present
> Status of the
mouth

The paradigm shows the relationship of oral care using toothbrush or

tongue depressor and the status of the mouth, and the number of colonies
and type of microorganisms present in the oral cavity. In the experimental
group, tongue depressor with gauze pad soaked in a Colgate Plax solution
will be used as a tool of oral care while in the controlled group, toothbrush
with Colgate toothpaste is the intervention used.
Hypothesis

There is no significant difference between toothbrush and tongue

depressor when it comes to the status of the mouth using the oral

assessment tool.
There is no significant difference between toothbrush and tongue
depressor when it comes to the type of microorganisms found in the

oral cavity before and after using each method.

There is no significant difference between toothbrush and tongue
depressor when it comes to the colonies of microorganisms present in

the oral cavity before and after using each method.

Main Variables
Toothbrush and tongue depressor are the independent variables in the
study. The status of the mouth, the number of colonies and the type of
microorganisms in the oral cavity of conscious elderly patients with NGT are
the dependent variables in the study.

Definition of Terms

Oral Assessment Tool

Operational definition: These will be used to assess the status of the mouth
by scoring from 1-7 the part of the assessment tool.
Colonies of microorganism
Operational definition:

These will be counted manually in the agar plate

after two days of incubation using the naked eye to determine the effect of
interventions compared.

Elderly patient
Operational definition: These are the subjects of the study aged 60-90 years
old, conscious and with NGT.
Oral cavity
Operational definition: Area of the mouth where sample for the colonies of
microorganism will be obtained for bacterial cultivation.
Tongue depressor
Operational definition: a gauze pad will be attached to tongue depressor and
soaked in a 15 mL Colgate Plax solution that will be tested in soft and hard
palate of the mouth used as an oral care in Experimental Group.
Tooth brush

Operational definition: Toothbrush with half-filled Colgate toothpaste will be

tested in soft and hard palate of the mouth used as oral care in Control
Group.

CHAPTER III
RESEARCH METHODOLOGY
This chapter provides the discussion of the research design, the design
used; Population and sample, the inclusion and exclusion criteria, how the
subjects are selected; research locale, where will the research study be
conducted; the data collection procedures and the statistical treatment of
data.
Research Design
The design used is a quasi experimental non equivalent control group
before and after design, which involves an experimental treatment group and
a control group of subjects observed before and after implementation (Polit,

et. Al.,2008). The purpose of this is to evaluate the effect of these two oral
care tools in the status of the mouth, and the type and number of colonies in
the oral cavity.
Two groups will be evaluated in the study, the experimental group
which is the use of tongue depressor with gauze pad soaked in a colgate plax
solution and the control group which will use toothbrush with colgate
toothpaste.

Population and Sample

The respondents covered by this present study are 20 conscious
elderly patients with Nasogastric tube. The respondents are divided into two
respective groups, the respondents who uses the toothbrush for oral care is
the control group while the respondents who uses the tongue depressor for
oral care is the experimental group. Each group will have 10 respondents.
The inclusion criteria in this study are; (1) patient with an age ranging to
60 to 90 years old (2) conscious (3) with nasogastric tube (4) without
respiratory problem (5) without mechanical ventilator (6) without any oral
infection or mouth diseases (7) without orthodontic braces. While the
exclusion criteria in this study are (1) patient with of 60 below and 90
above (2) unconscious (3) without nasogastric tube (4) with respiratory
problem (5) with mechanical ventilator (6) with oral infection or mouth
diseases (7) with dentures (8) with orthodontic braces.

The samples will be selected using the non-probability sampling

because the elements are selected by a nonrandom method. It is to estimate
the probability that each element has a chance of being included in a
probability sample. Purposive or judgmental sampling is used in this present
study. Because the researchers consciously select specific elements or
subjects for inclusion in a study in order to ensure that the elements will
have certain characteristics relevant to the study and the researcher recruits
subjects who are knowledgeable and well-experienced in the study.

Research Locale
This research study will be conducted at Ospital ng Sampalok, a
Secondary Hospital. The data will be collected from conscious elderly
patients with NGT at the Medical-Surgical ward of the hospital. The
researchers have been exposed within the said location and saw that many
patients in the Medical-Surgical Ward have Nasogastric Tube and most of
them are geriatric patients.
Data Collection Procedure
The researchers will obtain approval from the institution. Then, obtain
informed consent from the patient. Inform the patient of what will be done
before, during and after the procedure. Before collection of microorganisms
in the oral cavity, oral assessment will be done first to determine the

condition of the mouth using the oral assessment tool. Using the oral
assessment tool, the mouth of the patient will be assessed and scored
conforming to the criteria indicated in the tool. The areas to be assessed are
as follows:
1.
2.
3.
4.
5.

Voice- converse with patients and listen.

Swallow- ask the patients to swallow, and test gag reflex.
Lips- observe and palpate the tissue.
Tongue- observe the appearance of the tissue.
Saliva- insert tongue depressor and observe tongue and floor of the

mouth.
6. Mucous membrane and gingiva- observe appearance of the tissue.
7. Teeth or denture- observe appearance.

The colonies of microorganism will be collected in the oral cavity of

conscious elderly patients with NGT. Sample will be collected by rubbing a
cotton swab in the oral mucosa. After the sample collection, the cotton
swab will be placed in a test tube with distilled water. One hour after
sample collection, oral care will be provided by using toothbrush with
Colgate toothpaste using a sulcular technique for controlled group and
tongue depressor with Colgate Plax solution as a

for the experimental

group. One hour after oral care, sample will be collected in the same
way/manner for comparison. After the intervention, the sample will be
taken to the laboratory for bacterial cultivation. Swab method procedure
will be used to cultivate the sample. The researchers will then count the
number of colonies of microorganisms and classify it accordingly. The

results of the laboratory will then be compared and analyzed by the

researcher. Results will be provided and explained to the patients
involved.
Procedure 1: Sulcular Toothbrushing Technique
a) Place the bristles at a 45 degree angle. The tip of the outer bristles
should rest against and penetrate under the gingival sulcus. The brush
will clean the sulcus of two or three teeth one time.
b) Move the bristles up and down gently in short strokes from the sulcus
to the crowns of the teeth.
c) Repeat until all outer and inner surfaces of the teeth and sulci of the
gums are cleaned.
d) Clean the biting surfaces by moving the brush back and forth over
them in short strokes.
e) Brush the tongue gently with the toothbrush.
f) Hand the client the water cup or mouthwash to rinse the mouth
vigorously. Then ask the client to spit out water and excess dentifrice
into the basin.
Procedure 2: Swab Method Procedure
1. Aseptically inoculate one portion of pre-poured nutrient agar plate with
the swab, turning the swab as you streak on the agar in order to
transfer more inoculums. Discard the swab.
2. Pick a fresh swab and streak perpendicular to the original streaking, as
you would do with a loop in streak dilution method. Discard the swab.
3. Continue perpendicular streaking with fresh swab until you cover the
whole plate.
4. Incubate plate inverted in the incubator for 24-48 hours.

5. Reserve the plate for the next activity. Place in a refrigerator.

Ethical Considerations
Approval for the study will be obtained from the institution. All patients
and staff who will take part in the study will be provided with written and
verbal information. They will have at least 24-48 hours in which to decide
whether to take part in the study. A written informed consent will be signed
before the research procedure. To minimize harm and discomfort, procedures
will be done under the supervision of an attending nurse.

Statistical Treatment of Data

The status of the mouth of the subjects of both the control and
experimental group will be assessed and scored conforming to the criteria
set by the oral assessment tool.
Number of colonies of microorganism will be counted manually in the
agar plate in each 10 patients both in the Experimental group and Control
group, using the naked eyes.
The Types of microorganism will be identified under the microscope in
each 10 patients both in the Experimental Group and Controlled Group, using
staining methods.
1. t Test for Independent Groups

t Test is a parametrical statistical test for analyzing the difference

between two means. t Test for independent groups will be used for it will
test the significant difference between toothbrush and tongue depressor.
t-Test independent formula:

t=

x 1x 2

s21 s22
+
n1 n2

Where:
x1 = mean for Experimental Group 1
x2 = mean for Experimental Group 2
= Hypothesized difference between the population means
n1 = number of subjects in Experimental Group 1
n2 = number of subjects in Experimental Group 2
s1 = standard deviation of experimental group 1
s2 = standard deviation of experimental group 2

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

INFORMED CONSENT FORM

`I understand that I am being asked to participate in a research study
of Far Eastern University Manila Institute of Nursing Level III students at
Ospital ng Sampaloc. This research study will correlate the effect of oral care
using toothbrush and tongue depressor on the number of colonies of
microorganisms in the oral cavity of elderly patients with nasogastric tube. If
I agree to participate in this study, the researchers will collect a specimen
sample on my oral cavity (mouth)

twice only for one day. The samples will

be collected first thing in the morning and after patient had eaten breakfast

approximately after an interval of 1 hour after the treatment. I understand

that I will be using either toothbrush or tongue depressor after eating
breakfast.
I realize that I may not participate in this study, if I am younger than 50
years old and older than 90 years old, conscious, with nasogastric tube;
without mechanical ventilator and respiratory problem.
I realize that the knowledge gained from this study may help both me
and other elderly patient with nasogastric tube.
I realize that my participation in this study is entirely voluntary, and I
may withdraw from the study at any time I wish. I f I decide to discontinue
my participation in this study, I will continue to be treated in the usual and
customary fashion.
I understand that all study data will be confidential will be kept
confidential. However, this information may be used in nursing publications
or presentations.
I understand that if I sustain injuries from my participation in this
research project, I will not be automatically compensated by Ospital ng
Sampaloc.
If I need, I can contact (Adviser), the leader and the clinical instructor,
Institute of Nursing, any time during this study.

The study has been explained to me. I HAVE READ AND UNDERSTAND
THIS CONSENT FORM, ALL OF MY QUESTIONS HAVE BEEN ANSWERED, AND I
AGREE TO PARTICIPATE. I understand that I will be given a copy of this signed
consent form.

Signature of subject

Date

Signature of Witness

Date

Signature of Investigator

Date

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