Form Isp 6-713 - Consent To Toxicology

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CONSENT TO TOXICOLOGY

***FORM REQUIRED FOR ANALYSIS***

This Consent will be void if not signed and witnessed within 30 days after collection of the urine sample.

________________________________’s urine sample was collected on __________ at __________a.m./p.m.

(Name of victim)

(Date)

(Time)

Part One: CONSENT TO TOXICOLOGY SCREEN

I, _______________________________________________, authorize the Illinois State Police Forensic Science

(Victim (or if under 13 years), parent

, guardian

, law enforcement officer

, or DCFS

)

Laboratory to conduct a toxicology screen on ______________________________’s urine sample collected at

(Name of victim)

__________________________________ on the date and time specified above.

(Name of hospital)

I understand that alcohol and all drug residues (legal and illegal) in the urine will be disclosed by this test

and reported. I understand that this test is completely voluntary.

SIGNATURE:______________________________________ Date:____________ Time:_____________

(Victim (or if under 13 years), parent

, guardian

, law enforcement officer

, or DCFS

)

WITNESS:________________________________________ Date: ____________ Time:_____________

Part Two: RECEIPT OF EVIDENCE FOR TOXICOLOGY SCREEN

I certify that I received the urine specimen from the above-named victim for the purposes of toxicology

screening. I am aware that the victim, parent, or guardian may consent to the toxicology screening any time

within 30 days of the sample collection.

_________________________________

______________

_____________

______________

(Signature of officer receiving specimen)

(ID # and rank)

(Date)

(Time)

Law Enforcement Agency:__________________________________________________ Agency Phone:____________________________________

Hospital representative releasing specimen:__________________________________________ __________________________________________

(Printed name)

(Signature)

This revocation will be void if not signed within 48 hours after the Part One consent is signed.

Part Three: REVOCATION OF CONSENT FOR TOXICOLOGY SCREEN

(DO NOT FILL OUT THIS SECTION UNLESS CONSENT IS BEING WITHDRAWN)

I, ____________________________________, revoke my consent for the Illinois State Police Forensic Science

(Victim (or if under 13 years), parent

, guardian

, law enforcement officer

, or DCFS

)

Laboratory to conduct a toxicology screen on ______________________________’s urine sample collected at

(Name)

_______________________________ on ________________ at _____________a.m./p.m.

(Name of hospital)

(Date)

(Time)

SIGNATURE:________________________ Date: _________________ Time: _________________

(Victim (or if under 13 years), parent

, guardian

, law enforcement officer

, or DCFS

)

WITNESS:__________________________ Date: __________________ Time:__________________

Investigator must immediately notify the Springfield Forensic Laboratory (217-782-4975) or Forensic Science Center at Chicago (312-433-8000) if consent is revoked.

Original consent form must be included with the evidence and submitted to an ISP Laboratory through a Law Enforcement Agency. A copy must be provided to the

victim. Hospital and Law Enforcement Agency may keep a copy as needed.

ISP 6-713 (4/12)