Chemical Agent Testing - Chain Of Custody
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1Chemical Agent Testing - Chain of Custody
MDHHS-Bureau of Laboratories
3350 North Martin Luther King Jr. Blvd., Lansing MI 48906
Phone: 517-335-8059 (Laboratory Records)
517-335-9490 (Technical Information)
Fax: 517-335-9776
Web:
Page _______ of ________
Submitter Information:
Phone:
Fax:
Contact Person:
Telephone Number:
Collection Location:
Specimen Type
Blood
Urine
Specimen Information (Include a unique
Lab # (MDHHS Use Only)
Collection Date & Time
Collectors Initials
Identifying Number - must match label )
Date & Time
Transferred (Released) BY
Transferred (Released) TO
Reason for Transfer
Signature
Signature
Name (printed)
Name (printed)
Signature
Signature
Name (printed)
Name (printed)
Signature
Signature
Name (printed)
Name (printed)
Signature
Signature
Name (printed)
Name (printed)
(Enclose top white copy in plastic bag and send with specimens to MDHHS Laboratory. Use remaining copies for submitter, courier, etc. as needed)
DCH-1264 10/2015
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Parent category: Legal