Chain of Custody Assessment Form
Assess the custody history, transfer trail, item condition, and final integrity outcome for an item or sample.
Chain Details
Case or Reference Number
*
Item or Sample Identifier
*
Item or Sample Description
*
Date and Time of Initial Collection or Receipt
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Current Custody Status
*
Intact
Questionable
Broken
Unknown
Condition and Integrity Assessment
Overall chain integrity
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Evidence of tampering or unauthorized access
*
No
Possible
Yes
Observed discrepancies or condition issues
Assessment Result
Overall Chain-of-Custody Conclusion
*
Acceptable
Needs Review
Compromised
Recommended Next Action / Follow-Up
Submit
Should be Empty: