Form 9-505. Report of blood alcohol analysis.

[For use with Magistrate Court Rule 6-607 NMRA, Metropolitan Court Rule 7-607 NMRA and Municipal Court Rule 8-603 NMRA] ______________________________________________________________________ (Insert name of laboratory) REPORT OF BLOOD ALCOHOL ANALYSIS Laboratory number: ____________________________ Date received: ____________________________ Time received: ____________________________ ______________________________________________________________________ ______________________________________________________________________ PART A INFORMATION IN THIS BLOCK TO BE FILLED IN BY ARRESTING OFFICER SEND LAB ANALYSIS REPORT TO: Name: ______________________________ (Complete name of your agency) Address: ______________________________ (Street or P.O. box) ____________________________ (City, state and zip code) _____________________________________________________________________ _____________________________________________________________________ SEND COPY TO DONOR: Donor's identification: Name: ___________________________________________________________ __ (Last) (first) (middle) Address : ___________________________________________________________ __ (Street or post office box number) ___________________________________________________________ __ (City, state and zip code) Social security number: ___________________ Driver's license number: ___________________ Date of birth: ____________________________ Sex: ______________ Weight: ______________ ______________________________________________________________________ ______________________________________________________________________ BLOOD DRAW INFORMATION Date blood drawn: _________________________ Time blood drawn: ______________ (a.m.) (p.m.) Place drawn: ______________________________ Blood drawn by: ___________________________ Print name ___________________________ Signature Blood draw witnessed by: ___________________________ Print name ___________________________ Signature Remarks:_____________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ARREST INFORMATION Reason for law enforcement contact: [ ] Erratic driving ______________________________ [ ] Accident: [ ] Fatal [ ] Great bodily injury [ ] (other) _______________________________________ [ ] Other _____________________________________ Investigated or witnessed by: ___________________________ Print name ___________________________ Signature Arresting officer's identification: Department:_________________________________________ Date of arrest:_______________________________________ Place of arrest:_______________________________________ County: ____________________________________________ Arrest time: _______________________________ (a.m.) (p.m.) Arresting officer: ___________________________ Print name ___________________________ Signature _____________________________________________________________________ _____________________________________________________________________ INFORMATION BELOW IS TO BE FILLED IN BY DRAWER OF ANY BLOOD SAMPLE I certify that on the date, time and place indicated above, I drew blood samples from the above named donor and that I marked and sealed the samples with the donor's name. (For use in implied consent cases) _________ (initials) I certify that the blood was collected using the entire contents of a state scientific laboratory division approved blood collection kit in accordance with scientific laboratory division's approved instructions. ______________________________ Signature of blood drawer ___________________________ Date ______________________________ Title ______________________________ Employer name _____________________________________________________________________ _____________________________________________________________________ PART B - - - - - - - - - - - - - - - - - - - - - - LABORATORY USE ONLY - - - - - - - - - - - - - - - - - - - - CERTIFICATE OF RECEIVING EMPLOYEE Specimen of [ ] Blood [ ] Other __________ Received from ___________________________ Print name ___________________________ Signature [ ] In person [ ] via mail [ ] other ___________________________________________ Seal intact: Yes [ ] No [ ]. If No, explain: ____________________________________ ____________________________________________________________________ Other Remarks: _______________________________________________________ I certify that on the date shown in the "date received" blank above, I received the sample which accompanied this report and followed the procedures set out on the reverse of this report, and that the statements in this block are correct. Receiving employee ___________________________ Print name ___________________________ Signature _____________________________________________________________________ _____________________________________________________________________ CERTIFICATE OF ANALYST The seal of this sample was received intact and was broken in the laboratory: [ ] Yes [ ] No If No, explain: _________________________________________________________ RESULT OF ANALYSIS Blood Sample: ______________________________ gms/100 ml alcohol concentration in sample. REMARKS: ____________________________________________________________ ______________________________________________________________________ I certify that I followed the procedures set out on the reverse of this report, and that the statements in this block are correct. The concentration of alcohol in the sample is based on the grams of alcohol in one hundred milliliters of blood. Date of analysis: ______________________________ Analyzed by: ___________________________ Print name of analyst ___________________________ Signature of analyst CERTIFICATE OF REVIEWER I certify that the analyst who conducted the analysis in this case meets the qualifications required by the director of this laboratory to properly conduct such analyses; the supervisor of analysts is also qualified to conduct such analyses; and that the established procedure has been followed in the handling and analysis of the sample in this case. _____________________________ Date Reviewer: ___________________________ Print name ___________________________ Signature CERTIFICATE OF MAILING I certify that on this date I mailed a legible copy of this report to the donor, in accordance with the mailing procedure set out on the reverse of this report. _________________, ______ Date Laboratory employee: ___________________________ Print name ___________________________ Signature PROCEDURE (To be printed on the reverse side of report) 1. The laboratory named on the front of this report is a laboratory authorized or certified by the scientific laboratory division of the health department to perform blood and alcohol tests. The agency has established formal procedures for receipt, handling and testing of blood samples to assure integrity of the sample, a formal procedure for conduct and report of the chemical analysis of the samples by the gas chromatographic method (__________________) (specify, if other method used) and quality control procedures to validate the analyses. The quality control procedures include semi-annual proficiency testing by an independent agency. The procedures have the general acceptance and approval of the scientific community, including the medical profession, and of the courts, as a means of assuring a chemical analysis of a blood sample that accurately discloses the concentration of alcohol in the blood. The same procedures are applicable for samples other than blood if submitted for alcohol analysis. The analyst who conducts the analysis in this must meet the qualifications required by the director of this laboratory to properly conduct such analyses. The supervisor of analysts must also be qualified to conduct such analyses. 2. When a blood sample is received at the laboratory, the receiving employee examines the sample container and: (a) determines that it is a standard container of a kit approved by the director of the laboratory; (b) determines that the container is accompanied by this report, with Part A completed; (c) determines that the donor's name and the date that the sample was taken have already been entered on this report and on the container and that they correspond; (d) makes a log entry of the receipt of the sample and of any irregularity in the condition of the container or its seals; (e) places a laboratory number and the date of receipt on the log, on the container, and on this report, so that each has the same laboratory number and date of receipt; (f) completes and signs the Certificate of Receiving Employee, making specific notations as to any unusual circumstances, discrepancies, or irregularities in the condition or handling of the sample up to the time that the container and report are delivered to the analysis laboratory; (g) personally places the container with this report attached in a designated secure cabinet for the analyst or delivers it to the analyst. 3. When the blood sample is received by the analyst, the analyst: (a) makes sure the laboratory number on the container corresponds with the laboratory number on this report; (b) makes sure the analysis is conducted on the sample which accompanied this report at the time the report was received by the analyst; (c) conducts a chemical analysis of the sample and enters the results on this report; (d) retains the sample container and the raw data from the analysis; (e) completes and signs the Certificate of Analyst, noting any circumstance or condition which might affect the integrity of the sample or otherwise affect the validity of the analysis; (f) delivers this report to the reviewer. 4. The reviewer checks the calculations of the analysis, examines this report, signs the Certificate of Reviewer, and delivers the report to a laboratory employee for distribution. 5. An employee of the agency mails a copy of this report to the donor at the address shown on this report, by depositing it in an outgoing mail container which is maintained in the usual and ordinary course of business of the laboratory. The employee signs the certificate of mailing to the donor, and mails the original of this report to the submitting law enforcement agency. 6. The biological sample will be retained by the testing laboratory for a period of at least six (6) months pursuant to regulations of the scientific laboratory division.