District Court Rules of Small Claims Procedure 100

REPORT OF BLOOD ALCOHOL ANALYSIS

For use with Magistrate Court Rule 6-607, Metropolitan Court Rule 7-607 and Municipal Court Rule 8-603

(Insert name of laboratory)

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:

Address:

SEND COPY TO DONOR:

Donor's identification:

Name:

Address:

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:

Blood draw witnessed by:

Remarks:

ARREST INFORMATION

Reason for law enforcement contact:

Erratic driving

Accident: Fatal Great bodily injury

(other)

Other

Investigated or witnessed by:

Arresting officer's identification:

Department:

Date of arrest:

Place of arrest:

County:

Arrest time: (a.m.) (p.m.)

Arresting officer:

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) 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.

PART B

LABORATORY USE ONLY

CERTIFICATE OF RECEIVING EMPLOYEE

Specimen of Blood Other

Received from:

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:

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/100ml 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:

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:

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:

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 and quality control procedures to validate the 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.

USE NOTE

1. This form, after appropriate modifications, may also be used for controlled substance and other test reports.

[As amended, effective July 1, 1999; November 1, 2004.]