Laboratory Chain of Custody Form
Use this form to document sample collection, custody transfers, handling conditions, and final disposition for laboratory materials.
Sample and Submission Details
Sample ID / Specimen ID
*
Sample Name / Type
Please Select
Water
Soil
Blood
Urine
Swab
Tissue
Food
Chemical
Other
Sample Matrix / Material
Please Select
Aqueous
Solid
Liquid
Gas
Biological
Environmental
Other
Number of Containers / Aliquots
*
Collection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Collection Location / Site
Sample Condition at Receipt
Please Select
Intact
Leaking
Broken Seal
Temperature Issue
Other
Custody Transfer Information
From Custodian Name and Role
*
To Custodian Name and Role
*
Transfer Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Transfer Method
*
In-Person
Courier
Overnight Carrier
Internal Transfer
Other
Custody Status at Transfer
*
Released
Received
Rejected
Held
Returned
Storage, Handling, and Condition Tracking
Required Storage Condition
*
Please Select
Ambient
Refrigerated
Frozen
Protected from Light
Other
Storage Location / Identifier
*
Preservation Method or Additive Used
Seal Number / Tamper-Evident Seal Status
Handling Deviations, Damage, or Special Instructions
Analysis or Disposal Disposition
Intended Action
*
Test
Archive
Return
Dispose
Transfer to Another Lab
Requested Test or Analysis Type
Completion / Disposition Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Final Condition or Result Summary
Responsible Person Approving Final Disposition
*
Destination or Return Recipient
Submit
Should be Empty: