Chain of Custody Form

Section 9140.10  Chain of Custody Form All blood and urine specimens collected for testing shall be accompanied by a Chain of Custody Form, to be completed by the collector of a blood or urine specimen, the laboratory testing the blood or urine specimen or split specimen, and the MRO when applicable.  A Chain of Custody Form shall include all of the following information: a)         A section to be completed by the collector of the specimen, which includes all of the following information: 1)         The collector's name, address and phone number; 2)         The employee's name; 3)         The name of the employer; 4)         The name of the facility where the specimen was collected and its address and telephone number; 5)         The date and time that the specimen was collected; 6)         The date that the specimen was sent to a laboratory for testing; 7)         The name and address of the laboratory where the specimen will be sent for testing; 8)         For the collection of urine specimens, a section that indicates the temperature of urine specimens taken within 4 minutes after collection and any indication of the urine specimens unusual color, presence of foreign objects or material, or other signs of tampering; 9)         A statement for the collector to sign incorporating the following language: I certify that the specimen identified on this form is the specimen presented to me or collected by me and that it has been collected, labeled and sealed; and 10)         A place for remarks made by the collector of the specimen. b)        A section documenting the transfer of the specimen for the purpose of maintaining control and accountability for the specimen. At a minimum, this section shall indicate: 1)          Dates the specimen has been transferred; 2)          Signature and name of the person releasing the specimen; and 3)          Signature and name of the person receiving the specimen. c)         A section to be completed by the laboratory that indicates the following: 1)         An indication as to whether the specimen was received with intact specimen seals; 2)         The test results; 3)         A statement for the certifying scientist to sign incorporating the following language: I certify that the specimen has been examined upon receipt, analyzed, and that the results set forth are for that specimen; and 4)         A place for the certifying scientist to print his or her name, the signature of the certifying scientist, and the date. d)         A section to be completed by the MRO that includes the following: 1)         The name, address and telephone number of the MRO; 2)         The date the test results were received by the MRO; 3)         A statement for the MRO to sign incorporating the following language: I have reviewed and verified the laboratory tests for the specimen identified by this form; 4)         The determination of the test results as verified by the MRO; 5)         The time and date that the employee requested testing of a split specimen; and 6)         A place for remarks made by the MRO. e)         The Chain of Custody Form shall be comprised of the following copies for distribution: 1)         Original laboratory copy (Copy 1), which shall be routed to the laboratory with the specimen. 2)         Second original laboratory copy (Copy 2), which shall be routed to the laboratory with the specimen; as a means of reporting the test result, the laboratory will forward this copy to the MRO. 3)         Split specimen copy (Copy 3), which must be prepared by the laboratory testing the primary specimen and accompany the split specimen to the second laboratory if split testing has been requested by the employee. 4)         MRO copy (Copy 4), which shall be routed directly to the MRO by the collector. 5)         Employee copy (Copy 5), which shall be given to the employee by the collector of the specimen. 6)         Collector copy (Copy 6), which shall be retained by the collector. 7)         DER copy (Copy 7), which shall be forwarded to the DER by the MRO. f)         Retention of Chain of Custody Forms.  The collector, laboratory, laboratory testing the split specimen, MRO and DER shall retain their copies of the Chain of Custody Forms for a minimum of two years. g)         Transmission of Chain of Custody Forms.  Chain of custody forms shall be transmitted in a secure manner, which may include fax, courier, mail or electronic transmission through which security and confidentiality are maintained.