Medical Chain-of-Custody Form
Complete all sections to accurately record the transfer and handling of medical items or samples. This form is for operational chain-of-custody tracking purposes only.
Chain-of-Custody Record ID
*
Date and Time of Transfer
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Description of Item or Sample
*
Quantity
*
Current Location
*
Purpose of Transfer
*
Name and Role of Person Releasing Item
*
Name and Role of Person Receiving Item
*
Organization or Facility Involved
*
Signatures of Both Parties
*
Submit Chain-of-Custody Record
Submit Chain-of-Custody Record
Should be Empty: