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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