Fill and Sign the District Court Rules of Small Claims Procedure 100 General Form

9-505 [For use with Magistrate Court Rule 6-607, Metropolitan Court Rule 7-607 andMunicipal Court Rule 8-603] ________________________________________________________ (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: _______________ 2 ________________________________________________________________________ ________________________________________________________________________ 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.) 3 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 _____________________ 4 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 [ ] NoIf 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: __________________________ ________________________ Print name of analyst Signature of analyst 5 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; thesupervisor 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 anindependent 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 6 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 directorof 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 numberand 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 thatthe 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 thelaboratory 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; 7 (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 fordistribution. 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.]