时间______ 年______月______日______分至______年______月______日______分
　　地点：_________________________________________________________________
　　侦查人员姓名、单位：___________________________________________________
　　侦查目的_______________________________________________________________

　　过程及结果
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________

侦查员：____________
记录员：____________