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Do not seal submittal form inside evidence box.

IDAHO STATE POLICE

FORENSIC SERVICES
TOXICOLOGY SUBMITTAL FORM
Please fill out all information legibly, failure to do so may result in rejection of evidence and or delay of analysis
Date of Offense

Submitting Agency (Please do not abbreviate.)

Agency Case Number

County of Offense

Submitting Agency Address

Exhibit Number

Type of Toxicology Case/Charge (mark all that may apply)

DUI NJDT Probation Violation Sexual Assault * Homicide Other

(specify) ________________________________
DRE Opinion (specify)___________________________________________________________________
Is this a death investigation and/or fatality crash

Valid Breath Test Performed ?

Is sample from a Deceased Individual

Yes

No

No

No

Origin of Sample (mark one)

Suspect Victim Subject

Yes

Results: _____/_________

Name (last name first)

Investigating Officer please type or print

DOB

Investigator Email

Investigator Phone Number

Sample Collected by (name, title and facility):

Sample Type
Requested Analysis

Yes

Date/Time of Sample Collection:

Urine
Blood
Vitreous Humor (ethanol only)
1,2
Alcohol Toxicology 3 (drugs other than ethanol) Inhalants

Urine alcohol results may be of questionable value.

2
If a successful breath test was obtained, blood alcohol analysis will not be performed without prior justification.
3
If Toxicology analysis is required, Toxicology Specification Page is required or sample will be returned without analysis.
Analysis will be performed only up to the point of justifying the charge.
*Note approximate time of Sexual Assault, time of sample collection, suspected drugs and symptoms on Specification Page.

Chain of Custody
From

To

Date of Transfer

By submitting this evidence to Forensic Services, the agency agrees to the terms and conditions for analyzing this evidence as described at our website:
http://www.isp.state.id.us/forensic/index.html

For Forensic Services Use Only

Laboratory Case Number:

Outer Evidence Seals

Intact
Evidence Technician/Region:
Date:_______________
Non-intact (describe discrepancy)________________________________________________________________________________
Intact
Evidence Technician/Region:
Date:_______________
Non-intact (describe discrepancy)________________________________________________________________________________

THIS PAGE IS ONLY REQUIRED FOR SUSPECTED DRUGS OTHER THAN ALCOHOL
Idaho State Police...
Forensic Services.. .
Toxicology Specifications Form...
Idaho State Police Forensic Services Laboratory Number: __________________________________
(Lab Use Only)
Please Print Legibly
Failure to fully complete this form may result in rejection of evidence and/or delay of analysis
Case Information
Agency Case Number: __________________________ Agency Exhibit Number: ________________
Subject/Suspect/Victim Name:___________________________________________________________
Suspected Drugs

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Behavior/Symptoms Observed

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List Current Prescriptions, Over-the Counter Drugs, and/or Illicit Drugs

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Note: If blood alcohol testing is requested and the ethanol level is at or above a 0.10g/100cc and you
still require blood drug toxicology results, please provide information about extenuating circumstances
to justify additional blood drug toxicology analysis.
Extenuating Circumstances

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Notice
By submitting the evidence to Forensic Services, the agency agrees to the terms and conditions for
analyzing this evidence as described at our website:
http://www.isp.state.id.us/forensic/index.html