CHAIN OF CUSTODY FOR LEGAL ALCOHOLS

Subject’s Name: ________________________________________________________________________________
                                                                (PRINT NAME)

Subject’s Birthday: _________________________________________________                           Sex: _________________

Drawn By: ______________________________________________/______________________________________
                                                (PRINT NAME)                                                      (SIGNATURE)

Drawn on:Date _____________________________________            Time: ______________________________AM/PM

Location of drawing: _____________________________________________________________________________

Collected using a non-alcohol disinfectant from a vein not receiving medication of IV fluid. Completely fill 2 gray top tubes and invert gently to mix.

Label to tube with patient’s FIRST, and LAST NAME, DATE and TIME drawn, and initials of the person drawing the blood.
Seal tube and stopper, and label the seal with name of person affixing label and date and time. DO NOT cover the tube label with the seal.

Received from: _________________________________________________________________________________
                                                                    (PRINT NAME OF LAW OFFICER)

Law Enforcement Agency:(MARK ONE) _______ State Patrol     ______ Sheriff     ______ Police

County ___________________________________________             City_______________________________________

Received in MERCY LAB by: __________________________________/___________________________________
                                                (PRINT NAME)                                                    (SIGNATURE)

Received in MERCY LAB on: Date: _______________________           Time: ________________AM/PM

PHOTOCOPY THE FORM FOR THE LAW OFFICE. SEAL THE END OF THE ENVELOPE, INITIAL, LAW OFFICER INITIAL, AND PLACE IN LOCKBOX.

Additional chain of custody (if needed by non-MERCY locations)

Received by: ___________________________________________/________________________________________
                                        (PRINT NAME)                                                    (SIGNATURE)

Received on: Date:_________________________________                Time____________________________AM/PM

Received by:___________________________________________/________________________________________
                                         (PRINT NAME)                                                    (SIGNATURE)

Received on: Date:_________________________________                Time: ____________________________AM/PM