SOP 209.10-att-1: Drug Screen - Chain of Custody Form

4/30/15 DRUG SCREEN- CHAIN OF CUSTODY Attachment #1
SOP IIB01-0024 (209.10)

|1. Inmate's/Probationer's signature beside (2) indicates:
-- the urine sample is my own;
-- the sample has not been tampered with by me or anyone else;
-- either the container has been sealed in my presence or the sample has been
tested in my presence.
2. STAFF INITIALS beside inmate's/probationer's name and number indicates the staff
member either sealed or tested the sample in the inmate's/probationer's presence.
3. "REF" beside inmate's/probationer's signature indicates the inmate refused to provide
a sample. In this case, inmate's/probationer's signature endorses refusal to provide a
sample. If the inmate/probationer refuses to sign, the staff member should sign in the
inmate's/probationer's box.
4. A copy of this form should be attached to any disciplinary report resulting from
refusing to provide a sample.|Col2|Col3|Col4|C
O
C
A
I
N
E|C
A
N
N
A
B
I
N
O
I
D|M
E
T
H
A
Q
U
A
L
O
N
E|P
H
E
N
C
Y
L
I
D
I
N
E|B
E
N
D
I
A
Z
I
P
I
N
E|O
P
I
A
T
E
S|B
A
R
B
I
T
U
A
T
E
S|A
M
P
H
E
T
A
M
I
N
E
S|P
R
O
P
O
X
Y
P
H
E
N
E|C
H
E
C
K
I
F
+
R
E
S
U
L
T
S|L
A
B
S
T
A
F
F
I
N
I
T
I
A
L
S|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|(1) INMATE/PROBATIONER
STAFF INIT
NAME AND NUMBER
(2) SIGNATURE OF INMATE/
/PROBATIONER REF(?)|
DOB|
TIME|CONTAINER
NUMBER|QTY
+/-|QTY
+/-|QTY
+/-|QTY
+/-|QTY
+/-|QTY
+/-|QTY
+/-|QTY
+/-|QTY
+/-|||
|(1)
______
(2)
______|||||||||||||||
|(1)
______
(2)
______|||||||||||||||
|(1)
______
(2)
______|||||||||||||||
|(1)
______
(2)
______|||||||||||||||
|(1)
______
(2)
______|||||||||||||||
|(1)
______
(2)
______|||||||||||||||
|(1)
______
(2)
______|||||||||||||||

_________________________________ _________________ __________________________________________ _________________
STAFF IN CHARGE OF COLLECTION DATE & TIME RESULTS RECEIVED: DEP. WARDEN SECURITY/CHIEF OF SECURITY DATE & TIME
Copies: Care and Treatment/Ass. Supt./Chief Counselor

________________________________ __________________ IF CONFIRMATION REQUIRED, FORM RETURNED TO PROJECT SUPERVISOR:
STAFF IN CHARGE OF ANALYSIS DATE & TIME __________________________________ _____________________
STAFF IN CHARGE OF CONFIRMATION DATE & TIME SPECIMEN
SENT FOR CONFIRMATION

RETENTION SCHEDULE: Attachment 1 of this SOP, when complete will be filed locally and kept for one year if the results are negative. If the
results are positive, the form will become part of a disciplinary package that is placed in the inmate’s case history file. The case history file
is kept according to the official records retention schedule.