LABORATORY DRUG ANALYIS REQUEST
[pic] LABORATORY DRUG ANALYSIS REQUEST / CHAIN OF CUSTODY
( This sample is submitted by an active DRE, or
( This sample is NOT submitted by an active DRE, however payment for processing will be
billed to ____________________________ _______________________________________
Name / Agency Billing Address
Suspect’s Name:__________________________ DOB:_________ Age: _____ ( Male ( Female
Incident Date: ___________ Incident Time: _________ Incident City: _____________________
Specimen Collection Date:________ Collection Time: ________ Specimen Temperature: ____
Specimen Collection City:___________________ Arresting Officer ________________________
DRE’s Name:_______________________ DRE’s Agency: ____________________________
Send Results To:____________________ Send Copy To: _____________________________
Address: _________________________ Address: _________________________________
_________________________ _________________________________
_________________________ _________________________________
List all medications and/or illicit drugs found on or admittedly used by the suspect:
( Ambien ( Adderall ( Methylphenidate ( Klonopin ( Marijuana ( Methadone
( Oxycodone (Soma ( Hydrocodone (Suboxone ( Cocaine ( Xanax ( Heroin
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
A urine specimen is necessary for all drug categories except inhalants. A blood specimen is optional for all drug categories except inhalants. Blood screening will require prior approval from BHS.
Check suspected drug category
Supported by DRE evaluation
CNS Depressants _____
CNS Stimulants _____
Hallucinogens _____
Dissociative Anesthetics _____
Narcotics _____
Inhalants _____
Cannabinoids _____
-----------------------
Control Number
For Lab Use Only
CHAIN OF CUSTODY
From ________________ Time ________ Date ________
To __________________ Time ________ Date ________
To __________________ Time ________ Date ________
To __________________ Time ________ Date ________
................
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