Chain of Custody Form Supporting Lab Testing Samples as Potential Forensic Evidence

By mail Certified Lab Testing Including Paternity / DNA / Immigration / Cremains/Toxins /Postmortem Tissue/ Poisons / Date Rape Drugs/ Heavy Metals and More

 

Average test result turn around time, 16-20 business days, most cases.  Non-standard cases or test reruns require additional testing time. Express service is available

 

The Carlson Company LLC

Offering E-Z by Mail Certified DNA and Toxicology Lab Testing Services Worldwide

FREE real person client care 7 days a week     7AM - 10PM MST

TOLL FREE 1-866-889-3410                 LOCAL 719-531-6666                   EMAIL

6660 Delmonico Dr. Ste. D-425 Colorado Springs, CO 80919

 

 Disclaimer: The Carlson Company LLC is not licensed to practice medicine or law

 

 
  • FREE CONSULTATION
  • Providing certified, confidential, private, toxicology and DNA lab testing services to meet your specific needs
  • No doctor's referral required
  • Convenient by mail test sample submission
  • Keep your identity anonymous when Chain of Custody is not a consideration

 

 

 

Why should I submit a Chain of Custody form?   

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 evidence in a civil or criminal suit.

 

Chain of Custody supports the origin of the test sample (s)

 

 

Be sure to have a witness or two attest to your sample collection by signing off on the CC form below

If your case involves the alleged use of sexual assault drugs or drugs related to an alleged poisoning incident (s) we recommend that you submit at least one time/date stamp picture related to the test sample collection clearly showing the face of the test sample donor.

A CD/DVD recording is also acceptable. Your completed Chain of Custody form and picture will be retained as part your case file.

Note regarding minors: We are required by law to report to a local law enforcement agency any detectable levels of an illicit drug detected in any personal test samples belonging to a minor under eighteen (18) years of age. The detection of an illicit drug may be related to some type of child abuse.

 

 

 

 

Printable Chain of Custody Form

 

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

Sample Donor's Name _______________________________________________________________Age_________

Address _____________________________________________City __________________________State_______

Zip Code _____________ Phone ___________________Email___________________________________________

Is the sample donor deceased?      Yes________      No_______

Request for Lab Test Evaluation of Physical Samples with Chain of Custody

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.

X Sample submitter's name (print) _________________________________________________________________

X Signature_____________________________________________________________________________________

X Street address:________________________________________________________________________________

X City ___________________________State _____________Zip ________________Phone____________________

X Email_________________________________________________________________________________________

Requested Testing

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

(semen/sperm detection) - DNA extraction/comparison - female DNA presence - saliva  - lipstick -

date rape drugs (Ketamine, Rohypnol, GHB, plus seven (7) benzodiazepine derivative drugs and unknowns,

expanded date rape drug test - five (5) or ten (10) panel rave drug test - ten(10) panel drugs of abuse  

heavy metals test - expanded heavy metals test - antifreeze - cremains DNA - cremains heavy metals.

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__________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Page 1 of  2    Revised 02/04/10

 

Chain of Custody

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. I then

surrendered the sealed sample envelope or container to (circle one) USPS - UPS - FEDEX for shipping to The Carlson Company LLC.

X Witness #1 to the sample collection - Name (print) _______________________________________________________________________

X Witness to sample collection - Signature __________________________________________________________Date_____/______/______

X Email _______________________________________________________________________________________Phone__________________

X Witness #2 to the sample collection - Name (print) _______________________________________________________________________

X Witness to sample collection - Signature __________________________________________________________Date_____/______/______

X 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  

Page 2 of  2    Revised 02/04/10

End print Chain of Custody form here   

You will receive your certified lab report by phone, 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__________

 

Average test result turn around time, 16-20 business days, most cases.  Retests and non-standard cases often require additional testing time.

Reduce your test result turn around time by requesting Express Service. Additional testing fees apply.

 

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 02/04/10