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					CoCForm_Ext-Orgs.qxd              14/04/2004           5:51 PM            Page 1




                                      CHAIN OF CUSTODY FORM                                                                                                                     TEST AUTHORISED BY



                                                                                                                                                                           AUTHORISED COLLECTION AGENCY
      1. DOPING CONTROL SESSION
                                                                                                                                                     TEST
                                                                                             OUT OF                         IN                   MISSION
  DCO NAME                                                                              COMPETITION               COMPETITION                       CODE

      TEST                                                                                                                                                                          NUMBER OF
  LOCATION       CITY                                     STATE                                              COUNTRY                                                                  SAMPLES
                                                                                                                                                                                                          URINE            BLOOD

                                                                                                                                                                                   TIME SESSION
      SPORT                                                                                           DATE                                                                           COMPLETED
                                                                                                                  DD              MM                         YYYY

      2. SAMPLE ID

   A/B                                                                    A/B                                                                      A/B

   A/B                                                                    A/B                                                                      A/B

   A/B                                                                    A/B                                                                      A/B

   A/B                                                                    A/B                                                                      A/B

   A/B                                                                    A/B                                                                      A/B
      3.TRANSPORTATION AND STORAGE

       FROM                                                                                              TO
  (LOCATION)                                                                                     (LOCATION)

                                                                                                             ARRIVAL                                                                     ARRIVAL
               DATE                                                        TIME                                DATE                                                                         TIME
                            DD   MM             YYYY                                                                      DD                MM                      YYYY

                                                                                                        DEPARTURE                                                                     DEPARTURE
                                                                                                             DATE                                                                          TIME
                                                                                                                          DD                MM                      YYYY


                      DCO                                                                                           DCO
                SIGNATURE                                                                                     SIGNATURE


          TO                                                                                            TO
  (LOCATION)                                                                                    (LOCATION)

            ARRIVAL                                                     ARRIVAL                              ARRIVAL                                                                     ARRIVAL
              DATE                                                         TIME                                DATE                                                                         TIME
                            DD   MM            YYYY                                                                       DD                MM                      YYYY

       DEPARTURE                                                     DEPARTURE                          DEPARTURE                                                                     DEPARTURE
            DATE                                                          TIME                               DATE                                                                          TIME
                            DD   MM            YYYY                                                                       DD                MM                      YYYY


                      DCO                                                                                           DCO
                SIGNATURE                                                                                     SIGNATURE


           TO                                                                                           TO
   (LOCATION)                                                                                   (LOCATION)

            ARRIVAL                                                     ARRIVAL                              ARRIVAL                                                                     ARRIVAL
              DATE                                                         TIME                                DATE                                                                         TIME
                            DD   MM            YYYY                                                                       DD                MM                      YYYY

       DEPARTURE                                                     DEPARTURE                          DEPARTURE                                                                     DEPARTURE
            DATE                                                          TIME                               DATE                                                                          TIME
                            DD   MM            YYYY                                                                       DD                MM                      YYYY


                      DCO                                                                                           DCO
                SIGNATURE                                                                                     SIGNATURE


      4. DCO TRANSFER TO LABORATORY, COURIER OR OTHER
                                                                                                                                                                                       DROP-OFF
       DCO                                                                                                                                                                                 TIME
                                                                                                               DATE
      NAME
                                                                                                                          DD                MM                      YYYY


  IF TRANSFERRED TO LABORATORY
    LAB REP.                                                              LAB REP.                                                                       LAB REP.
      NAME                                                               POSITION                                                                     SIGNATURE

  IF TRANSFERRED TO COURIER
  COMPANY                                                                 WAYBILL                                                                       COURIER
     NAME                                                                 NUMBER                                                                      SIGNATURE

  IF TRANSFERRED TO OTHER
      OTHER                                                                OTHER                                                                          OTHER
       NAME                                                              POSITION                                                                     SIGNATURE



 ORIGINAL - ADO - WHITE                 COPY 1 - AUTHORISED COLLECTION AGENCY - GREEN                                  COPY 2 - LABORATORY - YELLOW                                                          VERSION 2: 04-2004 (WADA/AMA)

				
DOCUMENT INFO
Description: This is an example of chain of custody form. This document is useful for conducting chain of custody form.