Drug Test Custody Form
Document the chain-of-custody for a drug test sample, including collection, transfer, sealing, and receipt details.
Sample ID or Reference Number
*
Date and Time of Collection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Sample Collector Name
*
Location of Collection
*
Sample Sealed By (Name)
*
Date and Time of Sealing
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Recipient Name (Person Receiving Sample)
*
Date and Time of Transfer to Recipient
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Condition of Seal Upon Receipt
*
Intact
Broken
Other
Recipient Signature
*
Submit Custody Record
Submit Custody Record
Should be Empty: