Get documents about "evidence chain of custody
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This is an example of evidence chain of custody. This document is useful for conducting evidence chain of custody.
Document Sample
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
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