"Blood Alcohol Conversion Request Form" - Connecticut

Blood Alcohol Conversion Request Form is a legal document that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut.

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Download "Blood Alcohol Conversion Request Form" - Connecticut

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Blood Alcohol Conversion Request
Fax to: 203-639-6484 or Email to: CT.ForensicLab@ct.gov
Attach:
 Request for Analysis Form (SOP-ER-02:1 Rev 3 01/01/2017 )
Type of examination is “Blood Alcohol Conversion”
(In LEAS, or PDF from http://ct.gov/despp click “Scientific Services”)
 Hospital’s blood/urine result, medical record for subject
Provide the ETOH / Ethanol record page only
Ensure the hospital name & address is on it and the subject’s full name
Trooper / Officer:
_____________________________________
Troop / PD:
_____________________________________
Agency Contact Number:
_____________________________________
Agency Fax Number:
_____________________________________
Subject’s Name:
_____________________________________
Agency Case Number:
_____________________________________
Hospital Name:
_____________________________________
Hospital Full Address:
_____________________________________
_____________________________________
For questions contact Case Management at: 203-427-4098 or 203-639-6494
The sender of this document is a criminal justice agency responsible for the management of privileged information subject to
certain state and federal disclosure laws. The contents of this document may include such information as either an intended or
unintended recipient of such information. You are warned that any disclosure or other unauthorized use of this document or
information contained in it may constitute a violation of law. If you have received this material in error or are otherwise unable to
route it to the intended recipient, you are requested to contact the sender immediately.
Blood Alcohol Conversion Request
Fax to: 203-639-6484 or Email to: CT.ForensicLab@ct.gov
Attach:
 Request for Analysis Form (SOP-ER-02:1 Rev 3 01/01/2017 )
Type of examination is “Blood Alcohol Conversion”
(In LEAS, or PDF from http://ct.gov/despp click “Scientific Services”)
 Hospital’s blood/urine result, medical record for subject
Provide the ETOH / Ethanol record page only
Ensure the hospital name & address is on it and the subject’s full name
Trooper / Officer:
_____________________________________
Troop / PD:
_____________________________________
Agency Contact Number:
_____________________________________
Agency Fax Number:
_____________________________________
Subject’s Name:
_____________________________________
Agency Case Number:
_____________________________________
Hospital Name:
_____________________________________
Hospital Full Address:
_____________________________________
_____________________________________
For questions contact Case Management at: 203-427-4098 or 203-639-6494
The sender of this document is a criminal justice agency responsible for the management of privileged information subject to
certain state and federal disclosure laws. The contents of this document may include such information as either an intended or
unintended recipient of such information. You are warned that any disclosure or other unauthorized use of this document or
information contained in it may constitute a violation of law. If you have received this material in error or are otherwise unable to
route it to the intended recipient, you are requested to contact the sender immediately.