Chain of Custody Document
Submitting Activity ⃞ This article has been deemed a credible threat by local law enforcement, with consultation from MT DES (Disaster and Emergency Services Division), 841-3911 and/or the FBI. ⃞ Local health department has been contacted: ___________________________
Name of Health Department Official contacted
⃞ This article has been evaluated and/or tested for explosives and screened for radiological and chemical hazards
_________________________________________
Name and Title of Responsible person(s)
Name and Title of Person Requesting Testing: (results will be reported to this individual) Address: Location from Where Obtained: Description of Item to Be Tested: Name and Title of Person Collecting Article: (if different from above) Date Collected Time Collected Contact Phone#:
For Laboratory Use
Article Received from: (name, title, federal express package, etc) Description of Articles
1
Chain of Custody
Date & Time
Signature Name, Title Signature Name, Title
Released By
Signature Name, Title Signature Name, Title
Received By
Purpose of Change in Custody
For Lab Use Only
Turn form over for additional Chain of Custody blanks
Chain of Custody
Date & Time Released By
Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title Signature Name, Title
Received By
Purpose of Change in Custody
Final Disposal Action
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⃞ ⃞
Released to: __________________________________________ Destroyed: ________________ ___________________________________
Date Name, Title Signature
_____________________________________________________________ Witness to Destruction of Article(s)
The article(s) listed above was(were) destroyed by the evidence custodian, in my presence, on the date indicated above.
___________________________________ ______________________________
Name,Title Signature
3