evidence chain of custody

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					             West Virginia Department of Health and Human Resources                             167th 11th Avenue
                                                                                                South Charleston, WV 25303
             Bureau of Public Health, Office of Laboratory Services                             Phone: 304-558-3530 x 2301
             Threat-Preparedness and Response Section                                           Fax:       304-558-2006
                                                                                                4710 Chimney Drive, Suite G
                                                                                                Charleston, WV 25302
EVIDENCE / CHAIN OF CUSTODY DOCUMENT                                                            Phone: 304-558-0197
                                                                                                Fax:     304-558-4143


1.    SAMPLE:                                                       2. DATE COLLECTED:                  3. EOC NUMBER:


4.    COLLECTED BY:                                                 5. COUNTY:                          6. OLS LAB NUMBER:


7.    SAMPLE DESCRIPTION: (Number, Quantity, Type, Packaging, etc.)                                      Clinical Sample
                                                                                                         Environmental Sample




8.    INCIDENT LOCATION:

9.    SUSPECTED BIOLOGICAL / CHEMICAL TERRORISM AGENT(S):
 Bio-terrorism Agent(s)                                           Chemical Terrorism Agent(s)

      Anthrax,     Plague,     Tularemia,         Brucella,          Nerve Agent,         Blister Agent/Vesicant,

      Unknown,      Other _______________________                     Blood Agent,        Choking Agent/Irritant Agent,

                                                                      Riot Control,       Unknown,      Other ____________
Rationale:


10. SAMPLE RECEIVED FROM:
Organization: __________________________________________ Date: __________________ Time: ________________________

Address: ______________________________________________________________________ Phone: _______________________

Received from: ________________________________________________________________________________ [Sign in Section 11]

Witnessed by: _________________________________________________________________ Date: _________________________

Received via:      US Mail,     Hand Delivered,         Shipped via __________________________________________________

11.      SAMPLE ACKNOWLEDGEMENT:
 Sample Received from   Date/Time                      Sample Received by:        Sample Received by:               Remarks
      [signature]                                          [signature]               [print name]




12.          SAMPLE RELEASED TO:

Organization: __________________________________________ Date: __________________ Time: ________________________

Address: ______________________________________________________________________ Phone: ______________________

Received by: ________________________________________________________________________________ [Sign in Section 11]

Witnessed by: _________________________________________________________________ Date: ________________________

Transferred via:    US Mail,    Hand Delivered,        Shipped via _______________,       Sample Destroyed, Date: ________

13.          SAMPLE STORAGE CONDITIONS:




January 22, 2004                                    Attach additional pages as required                   Page _____ of _____
           West Virginia Department of Health and Human Resources                         167th 11th Avenue
                                                                                          South Charleston, WV 25303
           Bureau of Public Health, Office of Laboratory Services                         Phone: 304-558-3530 x 2301
           Threat-Preparedness and Response Section                                       Fax:       304-558-2006
                                                                                          4710 Chimney Drive, Suite G
                                                                                          Charleston, WV 25302
EVIDENCE / CHAIN OF CUSTODY DOCUMENT                                                      Phone: 304-558-0197
                                                                                          Fax:     304-558-4143




                                                    INSTRUCTIONS
                                   Please use BLUE Ink when completing this form
     HEADER – Check which OLS Laboratory initially received the sample from the originator.
1.   SAMPLE - The sample name that the originator has designated.
2.   DATE COLLECTED – The date that the sample was collected by the originator.
3.   EOC NUMBER - All samples must have an EOC (Emergency Operation Center) message number before being
     accepted. EOC message numbers are assigned by and obtained from the West Virginia Office of Emergency
     Services, Phone (304) 558-5380 (24 hour contact number).
4.   COLLECTED BY – The name of the originator (individual and/or organization) that collected the sample.
5.   COUNTY – The County in WV where the sample was collected.
6.   OLS LAB NUMBER - All samples must be assigned and labeled with a unique OLS Lab Number.
7.   SAMPLE DESCRIPTION – Describe the number, quantity, type, packaging, etc for the samples received. Check the
     appropriate box for clinical or environmental samples.
8.   INCIDENT LOCATION – List the location where the sample originated.
9.   SUSPECTED BIOLOGICAL / CHEMICAL TERRORISM AGENT(S) – If known, check the appropriate box for either
     bio-terrorism and/or chemical terrorism agents suspected. If agent is other, please check and list. Document the
     rationale for the suspected agents checked.
10. SAMPLE RECEIVED FROM – Detailed information about the originator (organization and individual) from whom the
     sample was received. If the sample is received via mail, UPS, FedEx, etc., a sample received from signature is not
     necessary, but the delivery receipt should be witnessed. Maintain copies of all shipping documents with the sample
     paperwork or attach to the Evidence / Chain of Custody Document.
11. SAMPLE ACKNOWLEDGEMENT – Individuals for which samples were received from, and received by, must sign
     when each transfer is made. Individuals receiving samples must also print their name.
12. SAMPLE RELEASED TO - Detailed information about the organization and/or individual to which the OLS released
     the sample. If the sample is released via mail, UPS, FedEx, etc., a sample received by signature is not necessary,
     but the delivery shipment should be witnessed. If the sample destroyed by OLS, the destruction date is recorded.
     Maintain copies of all shipping documents with the sample paperwork or attach to the Evidence / Chain of Custody
     Document.
13. SAMPLE STORAGE CONDITIONS – Conditions where and how the sample is/was stored and secured.
14. FOOTER – If required, attach addition pages as needed. Complete Sections 1, 3 and 6 on all subsequent pages
     and fill in the Page _____ of _____ on each page.




January 22, 2004                                Attach additional pages as required

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