Air Sample Chain of Custody Form
Use this form to document air sample collection, transfers, and laboratory receipt for custody tracking.
Collection Details
Collection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Sampling Location / Site Name
*
Exact Sample Location / Area
*
Project / Case Reference
Sample ID / Container ID
*
Sample Type / Media
*
Please Select
Ambient Air
Indoor Air
Personal Air
Stack Emissions
Ambient Particulate
Other
Collection Method / Instrument
*
Please Select
Filter Cassette
Sorbent Tube
Canister
Impinger
Pump-Based Sampler
Direct-Read Meter
Other
Field Notes / Observations
Custody Transfer Log
Custody Transfer Entries
*
Transfer event log details
Released by name
Released by role
Please Select
Collector
Sampler
Field Technician
Supervisor
Other
Received by name
Received by role
Please Select
Courier
Laboratory Staff
Supervisor
Field Technician
Other
Sample Condition and Laboratory Receipt
Sample condition upon receipt
*
Please Select
Intact
Damaged
Leaking
Seal broken
Temperature excursion noted
Other
Received date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Receiving technician or lab contact
*
First Name
Middle Name
Last Name
Laboratory name
*
Requested analysis/tests
*
Particulate matter
Volatile organic compounds
Metals
Asbestos
Silica
Mold
Other
Comments, discrepancies, or seal condition
Submit
Should be Empty: