In the realm of forensic toxicology, the Fm 016F form holds a pivotal role, streamlining the process of request and submission for toxicology analysis. As an essential document, it specifically caters to law enforcement agencies and medical examiners who seek comprehensive toxicological evaluations in cases ranging from vehicular incidents to substance abuse. With its structured format, the form requires detailed subject information including but not limited to name, gender, and identification details, furnishing clarity and precision right from the onset. The sample information section meticulously outlines the type and quantity of specimens collected, ensuring each sample is accurately accounted for. Furthermore, the agency information segment captures data of the requesting body, vital for maintaining communication and record accuracy. On the offense information front, the form accommodates a broad spectrum of scenarios, acknowledging the diverse nature of cases requiring toxicological insight. Another significant aspect is the sample submission checklist, designed to avert potential delays by verifying proper labeling and packaging of samples. The form's emphasis on a clear chain of custody underscores the importance of traceability and accountability in the handling of forensic evidence. Through this structured procedure, the Fm 016F form facilitates a thorough and efficient analysis, fostering precision and reliability in forensic investigations.
| Question | Answer |
|---|---|
| Form Name | Fm 016F Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | utah toxicology request form, THC, utah, Taylorsville |
Toxicology Analysis Request Form
NEW Mailing Address:
Evidence Receiving Phone: (801)
Evidence Receiving Fax: (801)
Email: forensictox@utah.gov
www.health.utah.gov/lab/toxicology
Bureau of Forensic Toxicology
Physical Address:
PO Box 144300
4431 South 2700 West
Salt Lake City, UT
Taylorsville, UT 84119
Enter information electronically and print a copy to submit with the samples. Submit ONE form per subject.
SUBJECT INFORMATION
Last Name
First Name
Middle Name
Gender: |
Male |
Female |
Date of Birth
ID#
ID type
State
Subject Type:
SAMPLE INFORMATION
Sample Type |
Number of Samples |
Collection |
Collection |
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Date |
Time (24:00) |
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Blood |
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1 |
2 |
3 |
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Urine |
0 |
1 |
2 |
3 |
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Samples collected by: |
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For BFT use only.
AGENCY INFORMATION
Agency Name
Requesting
Officer
Agency case#
County
OFFENSE INFORMATION
Offense Date |
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Time (24:00) |
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Incident Information (check all that apply)
DUI |
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DUI metabolite |
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Accident |
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Vehicular homicide |
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Fatal Accident |
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Other: |
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List any drugs suspected or administered for medical treatment prior to blood draw:
SAMPLE SUBMISSION CHECKLIST
To ensure your samples are processed without delays, please verify that:
The blood and urine samples are each labelled with the subject name, your agency case #, and the subject ID# or date of birth.
The tubes, containers, and packaging are each sealed, initialed, and dated.
This form is included with the sample.
Samples that do not meet the submission requirements will be returned .
TEST(S) REQUESTED
Alcohol
Drugs of Abuse (THC, Cocaine, Morphine, Meth)
Prescription Drug Panel *
*The current list of drugs included in the Prescription Drug Panel may be found in our Services Manual on our website.
CHAIN OF CUSTODY |
Samples were delivered by mail/courier. |
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Samples were delivered by agency personnel. Name: |
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Date |
Time
02/09/2010
LAW ENFORCEMENT AGENCY CHAIN OF CUSTODY REPORT for Toxicology Samples
Complete this chain of custody report and maintain for your records. Do NOT submit the chain of custody report to the laboratory.
SUBJECT INFORMATION |
Agency case# |
Last Name
First Name
Name
Date
Name
Date
Name
Date
Name
Date
Name
Date
Name
Date
Name
Date
From
Time
Time
Time
Time
Time
Time
Time
Name
Date
Name
Date
Name
Date
Name
Date
Name
Date
Name
Date
Name
Date
To
Time
Time
Time
Time
Time
Time
Time