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Chain of Custody Form
Supporting DNA or Toxicology Lab Testing Samples as Potential Forensic Evidence
Typical testing samples include hair, teeth, bones, food, urine, blood, nails, unknowns, capsules, post mortem tissue, saliva, semen, cremains, powders, liquids, and many more
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Why should I submit a
Chain of Custody form?
Chain of Custody supports the origin of the test sample
The submission of a completed "Chain of
Custody" form with your test sample is
strongly recommended but not required! The choice is yours.
Chain of Custody
defined is the unbroken trail of accountability that ensures the physical
security of samples, data, and records that may have potential as forensic
evidence.
Please print and complete the form below and submit with your test sample (s).
To print the Chain of Custody form left click your mouse and hold to highlight the form then right click, select print, then click print selection, then click print.
Begin print Chain of Custody form here
Revised 08/05/10
Page 1 of 2
Request for Lab Test Evaluation of Physical Samples with Chain of Custody
Sample Donor's Name _______________________________________________________________Age_________
Address _____________________________________________City __________________________State_______
Zip Code _____________ Phone ___________________Email___________________________________________
Is the sample donor deceased? Yes________ No_______
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Suspected Incident Date______ /_____/______ or over a period of time Sample Collection Date______ /_____/________ Sample Submission Date_____/_____/________ Brief test sample (s) description __________________________________________________________________ Brief scenario about this case_____________________________________________________________________ ______________________________________________________________________________________________ Sample Submitter I certify that I am submitting this test sample (s) (circle your choice) on my own behalf or on behalf of the identified sample donor shown above. If the donor and submitter are the same person write in, "same as donor" in the sample submitter name line below. Sample submitter's name (print) _________________________________________________________________ Signature_____________________________________________________________________________________ Address _____________________________________________City __________________________State_______ Zip Code _____________ Phone ___________________Email___________________________________________ Requested Testing Each submitted test sample must be tested as a stand alone evaluation, no combined test samples will be accepted. Please test (test descriptions) the submitted sample (s) for: circle your choice (each circled testing choice requires an appropriate testing fee) unknown chemicals and other toxins - unknown drug - infidelity , presence of a woman DNA detection - M/F saliva) - lipstick/cosmetics - basic date rape drugs (Ketamine, Rohypnol, GHB, etc.) expanded date rape drug test - five (5) panel illegal street drug test -ten (10) panel illegal street drug test - ten(10) panel street drugs of abuse heavy metals test - expanded heavy metals test - antifreeze - cremains DNA - cremains heavy metals - unknown substance. Unique test or sample? Please call 1-866-889-3410 (toll free seven days a week) if you need assistance. _________________________________________________________________________________________________ _________________________________________________________________________________________________ If applicable (not required for DNA, cremains, or infidelity testing) list specific prescription or non prescription drugs formerly or currently being taken by the sample donor over the past six (6) months__________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Chain of Custody - Continued Revised 08/05/10 Page 2 of 2 Witness or Witnesses to the Sample Collection The witness or witnesses (at least one is required) to the sample collection should sign their signature below including their printed name, date, email, and phone number. I, as a witness to the sample collection, confirm the identity of the sample donor and sample description as stated above. I certify that the test sample (s) being submitted represents an "as collected" sample. I did or did not (circle one) assist with the sample collection from the donor. I (witnessed) the said sample (s) being placed in an envelope or other suitable container for shipping and then sealed the envelope or container with a piece of tape. I then printed my name and the current date and time on the sealing tape to originate Chain of Custody. The sealed sample envelope or container was then surrendered to (circle one) USPS - UPS - FEDEX for shipping to The Carlson Company LLC. Witness #1 to the sample collection Name (print) ______________________________________________________________________________________________________ Signature __________________________________________________________________________________ Date_____/______/______ Email ______________________________________________________________________________________ Phone__________________ Witness #2 to the sample collection Name (print) _______________________________________________________________________________________________________ Witness to sample collection - Signature _________________________________________________________ Date_____/______/______ Email _______________________________________________________________________________________Phone_________________ Office use only Sample (s) received by The Carlson Company LLC from sample submitter __________________________________via - USPS - UPS - FEDEX Date______/______/______ Sample released by The Carlson Company LLC to _______________________________________________________via - USPS - UPS - FEDEX Date______/______/______ Sample received by ________________________________________from ___________________________________via - USPS - UPS - FEDEX Date______/______/______ Sample released by ________________________________________to _____________________________________via - USPS - UPS - FEDEX
End print Chain of Custody form here You will receive your certified lab report by phone or email (default) or USPS, your choice, with no additional charge. If you prefer to have your test report returned to you by UPS (United Parcel Service) with a tracking number please add an additional $20.00 to your testing fee. Please return my test results by UPS, check one, Yes__________ No__________
Our mailing address is The Carlson Company LLC 6660 Delmonico Dr. Suite D-425 Colorado Springs, CO 80919-1899
The Carlson Company LLC is woman owned © The Carlson Company LLC 2002-2010 All rights reserved Update 08/10/10 |
