Chain Of Custody Form
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1Form II.06/A
Chain of Custody Form
This document must accompany the specimen (i.e. bullet) at all times.
I, ___________________________, ____________________________ removed a specimen consisting of
Name
Title
a/several ___________________________ from ____________________________ at ______ on ______
Patient
time
Date
The specimen has been handled by the people listed below.
The last person on the list ______________________________________ of the specimen.
disposed/retained possession/handed over to police
1. ___________________________, ___________________________ transferred specimen to
Name
Title
_____________________, ___________________________ ___________, __________.
Name
Title
Date
Time
I, ___________________________, _____________________________ the specimen.
Name
process, if no action enter “only handled”
2. ___________________________, ___________________________ transferred specimen to
Name
Title
_____________________, ___________________________ ___________, __________.
Name
Title
Date
Time
I, ___________________________, _____________________________ the specimen.
Name
process, if no action enter “only handled”
3. ___________________________, ___________________________ transferred specimen to
Name
Title
_____________________, ___________________________ ___________, __________.
Name
Title
Date
Time
I, ___________________________, _____________________________ the specimen.
Name
process, if no action enter “only handled”
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