West Virginia Department of Health and Human Resources Bureau of Public Health, Office of Laboratory Services Threat-Preparedness and Response Section
167th 11th Avenue South Charleston, WV 25303 Phone: 304-558-3530 x 2301 Fax: 304-558-2006 4710 Chimney Drive, Suite G Charleston, WV 25302 Phone: 304-558-0197 Fax: 304-558-4143
EVIDENCE / CHAIN OF CUSTODY DOCUMENT
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. 9.
INCIDENT LOCATION: SUSPECTED BIOLOGICAL / CHEMICAL TERRORISM AGENT(S): Chemical Terrorism Agent(s) Tularemia, Brucella, Nerve Agent, Blood Agent, Riot Control, Blister Agent/Vesicant, Choking Agent/Irritant Agent, Unknown, Other ____________
Bio-terrorism Agent(s) Anthrax, Unknown, Rationale: Plague,
Other _______________________
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 [signature]
Sample Received by: [signature]
Sample Received by: [print name]
Remarks
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 Bureau of Public Health, Office of Laboratory Services Threat-Preparedness and Response Section
167th 11th Avenue South Charleston, WV 25303 Phone: 304-558-3530 x 2301 Fax: 304-558-2006 4710 Chimney Drive, Suite G Charleston, WV 25302 Phone: 304-558-0197 Fax: 304-558-4143
EVIDENCE / CHAIN OF CUSTODY DOCUMENT
INSTRUCTIONS Please use BLUE Ink when completing this form HEADER – Check which OLS Laboratory initially received the sample from the originator. 1. 2. 3. SAMPLE - The sample name that the originator has designated. DATE COLLECTED – The date that the sample was collected by the originator. 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. 5. 6. 7. COLLECTED BY – The name of the originator (individual and/or organization) that collected the sample. COUNTY – The County in WV where the sample was collected. OLS LAB NUMBER - All samples must be assigned and labeled with a unique OLS Lab Number. SAMPLE DESCRIPTION – Describe the number, quantity, type, packaging, etc for the samples received. Check the appropriate box for clinical or environmental samples. 8. 9. INCIDENT LOCATION – List the location where the sample originated. 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