Driving Under the Influence/DRE - Request for Analysis
|Washington State Toxicology Laboratory - Washington State Patrol |
| |
|2203 Airport Way S Ste 360 |
|Seattle WA 98134-2027 |
|Phone: (206) 262-6100 |
|Fax: (206) 262-6145 |
|e-mail: toxlab@wsp. |
|Subject’s Information: (Please print clearly) |Laboratory Use Only |
| |Laboratory # |
| | |
| |Date: |
|Name: | | | | |
| Last First | |
|MI | |
|Date of Birth: | / / |Sex:|DUI DRE |DRE Evaluator: |
| | |M | | |
| | |F | | |
|Agency Case # | |County | |
|Agency: | | |Analyst:____________ |
|Address: | | |Specimens Received: |
|City St Zip: | | |Note all volumes are approximate |
| | | | | |
|Case History: brief | | |ml | |
|description of the incident| | | | |
|and attach copy of the | | | | |
|investigation report/DRE | | | | |
|Face Sheet: | | | | |
| | | | | |
| | | | | |
| | | | |ml |
| | | |
|Drugs suspected or admitted: list symptoms, observations, drug history, prescriptions, etc. | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|Sample Information: | |Analysis |DRE Opinion: | |
| | |Requested: |(check box) | |
| | | |CNS | |
| | | |Depressants | |
| | | |CNS Stimulants| |
| | | | | |
| | | |Hallucinogens | |
| | | |Dissociative | |
| | | |Anesthetic | |
| | | |Narcotic | |
| | | |Analgesics | |
| | | |Inhalants | |
| | | |Cannabis | |
|From: | |
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Driving Under the Influence/DRE – Request for Analysis
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