Ct Laboratory Sample: Chain-Of-Custody Form
ADVERTISEMENT
1
2SC DEPARTMENT OF HEALTH AND
ENVIRONMENTAL CONTROL
BUREAU OF LABORATORIES
8231 Parklane Road Columbia, SC 29223
(803) 896-9725
B.O.L. ID # :
CT LABORATORY SAMPLE: CHAIN-OF-CUSTODY FORM
Date of Birth
Patient’s Name (Last)
(First)
(MI)
Collection Time
Collection Date
MO
DAY
YR
___AM
MO
DAY
YR
:
___PM
Social Security #
Hospital ID # / Information
Race
Sex
Patient Sticker
** Patient information on the sticker does not need to be
reentered in the gray portion of this form
Specimen Type
Patient Symptoms: Date of Onset:
/
/
____ Blood
____________________________________
____ EDTA – Purple
# ____
Sender
____________________________________
____ Green
# ____
____________________________________
____ Gray
# ____
____________________________________
(Optional)
____ Urine
Approx. Volume ______mL
Date:
Time:
1. Collected by:____________________________________/_____________________________________________________________________________
(Printed Name)
(Signature)
Reason:________________________________________________________________________________________________________________________
Date:
Time:
2. Received by:____________________________________/_____________________________________________________________________________
(Printed Name)
(Signature)
Reason:________________________________________________________________________________________________________________________
Date:
Time:
3. Received by:____________________________________/______________________________________________________________________________
(Printed Name)
(Signature)
Reason:________________________________________________________________________________________________________________________
Date:
Time:
4. Received by:____________________________________/_____________________________________________________________________________
(Printed Name)
(Signature)
Reason:________________________________________________________________________________________________________________________
Date:
Time:
5. Received by:____________________________________/_____________________________________________________________________________
(Printed Name)
(Signature)
Reason:________________________________________________________________________________________________________________________
CTU INTERNAL USE ONLY
Meets COC:
YES
NO
Comments: __________________________________________________________________________________________________________________
Signature: ______________________________________________________
Date: ______ / ______ / ______
DHEC 1374 (3/2005)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal