DOH Form 302-019 "Phl Biothreat Environmental Sample Submission Chain-Of-Custody Form" - Washington

What Is DOH Form 302-019?

This is a legal form that was released by the Washington State Department of Health - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Washington State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOH Form 302-019 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download DOH Form 302-019 "Phl Biothreat Environmental Sample Submission Chain-Of-Custody Form" - Washington

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State of Washington
Department of Health
PUBLIC HEALTH LABORATORIES
1610 N.E. 150th Street
Shoreline, WA 98155-9701
Phone (206) 418-5400
PHL USE ONLY
Fax (206) 418-5545
PHL BIOTHREAT ENVIRONMENTAL SAMPLE SUBMISSION
CHAIN-OF-CUSTODY FORM
INSTRUCTIONS: All samples submitted to the Public Health Labs for testing MUST follow the Notification Procedure for Suspected Threat
Incidents. You MUST receive verbal permission from the Washington State Epidemiology section prior to sending the sample. All samples
MUST be screened for EXPLOSIVES prior to submission to the Public Health Labs. No samples will be accepted without this screening. All
samples submitted for testing must include this fully completed submission form. Failure to fully complete this form may delay testing
results.
SAMPLE INFORMATION
SUBMITTER INFORMATION
1. DESCRIPTION OF SAMPLE
8. SUBMITTING AGENCY
9. SUBMITTER NAME
10. SUBMITTER STREET ADDRESS
2. TYPE OF MATERIAL (check all that apply):
POWDER
SOLID
LIQUID
GAS
MIXTURE ______________________
3. INCIDENT DESCRIPTION
11. COUNTY
12. STATE
13. ZIP
14. EMAIL
4. INCIDENT STREET ADDRESS
15. NAME OF PERSON RECEIVING REPORT
5. COUNTY OF INCIDENT
6. TIME OF COLLECTION
16. PHONE NO
17. FAX NO
AM
PM
(
)
(
)
7. RISK ASSESSMENT (check all that apply):
18. RISK ASSESMENT PERFORMED BY (Print name):
Stated or implied threat
NO
YES
Visible substance
NO
YES
19. SIGNATURE
19a. DATE/TIME
Uncertain or suspicious origin
NO
YES
Human Illness/casualties associated with Event
NO
YES
DATE: ____ / ____ / 20___
TIME: ______________ am / pm
No Apparent Risk Indicators
Low Risk Indicators
High Risk Indicators
MANDATORY NOTIFICATION PRIOR
FIELD HAZARD SCREENS OF SAMPLE
TO SUBMISSION
CONTACT NAME
DATE ____ /___/ 20___
ON-SITE INCIDENT
26. FEDRAL BUREAU
METHOD/
SCREEN
DATE/TIME
RESULTS
TECH ID
OF INVESTIGATION
INSTRUMENT
Phone number:
TIME ________ am / pm
(FBI)
(Did you test for?)
CONTACT NAME
DATE ____ /___/ 20___
20. Bomb Tech Screen*
27. LOCAL HEALTH
(if unopened)
DEPT
TIME_________am / pm
COUNTY
Yes
No
28. WA STATE
CONTACT NAME
DATE ____ /___/ 20___
21. Explosives*
EPIDEMIOLOGY
Yes
No
TIME_________ am / pm
22. Reactive Chemicals
Comments:
Yes
No
23. Chemical pH (wet)
Yes
No
24. Radioactivity
Yes
No
25. Volatile Organics
Yes
No
*ALL SAMPLES MUST BE PRE-SCREENED FOR EXPLOSIVES PRIOR TO ENTRY INTO THE PHL*
Page 1 of 2
Attention: (Two page form) DOH 302-019 (07/2016)
State of Washington
Department of Health
PUBLIC HEALTH LABORATORIES
1610 N.E. 150th Street
Shoreline, WA 98155-9701
Phone (206) 418-5400
PHL USE ONLY
Fax (206) 418-5545
PHL BIOTHREAT ENVIRONMENTAL SAMPLE SUBMISSION
CHAIN-OF-CUSTODY FORM
INSTRUCTIONS: All samples submitted to the Public Health Labs for testing MUST follow the Notification Procedure for Suspected Threat
Incidents. You MUST receive verbal permission from the Washington State Epidemiology section prior to sending the sample. All samples
MUST be screened for EXPLOSIVES prior to submission to the Public Health Labs. No samples will be accepted without this screening. All
samples submitted for testing must include this fully completed submission form. Failure to fully complete this form may delay testing
results.
SAMPLE INFORMATION
SUBMITTER INFORMATION
1. DESCRIPTION OF SAMPLE
8. SUBMITTING AGENCY
9. SUBMITTER NAME
10. SUBMITTER STREET ADDRESS
2. TYPE OF MATERIAL (check all that apply):
POWDER
SOLID
LIQUID
GAS
MIXTURE ______________________
3. INCIDENT DESCRIPTION
11. COUNTY
12. STATE
13. ZIP
14. EMAIL
4. INCIDENT STREET ADDRESS
15. NAME OF PERSON RECEIVING REPORT
5. COUNTY OF INCIDENT
6. TIME OF COLLECTION
16. PHONE NO
17. FAX NO
AM
PM
(
)
(
)
7. RISK ASSESSMENT (check all that apply):
18. RISK ASSESMENT PERFORMED BY (Print name):
Stated or implied threat
NO
YES
Visible substance
NO
YES
19. SIGNATURE
19a. DATE/TIME
Uncertain or suspicious origin
NO
YES
Human Illness/casualties associated with Event
NO
YES
DATE: ____ / ____ / 20___
TIME: ______________ am / pm
No Apparent Risk Indicators
Low Risk Indicators
High Risk Indicators
MANDATORY NOTIFICATION PRIOR
FIELD HAZARD SCREENS OF SAMPLE
TO SUBMISSION
CONTACT NAME
DATE ____ /___/ 20___
ON-SITE INCIDENT
26. FEDRAL BUREAU
METHOD/
SCREEN
DATE/TIME
RESULTS
TECH ID
OF INVESTIGATION
INSTRUMENT
Phone number:
TIME ________ am / pm
(FBI)
(Did you test for?)
CONTACT NAME
DATE ____ /___/ 20___
20. Bomb Tech Screen*
27. LOCAL HEALTH
(if unopened)
DEPT
TIME_________am / pm
COUNTY
Yes
No
28. WA STATE
CONTACT NAME
DATE ____ /___/ 20___
21. Explosives*
EPIDEMIOLOGY
Yes
No
TIME_________ am / pm
22. Reactive Chemicals
Comments:
Yes
No
23. Chemical pH (wet)
Yes
No
24. Radioactivity
Yes
No
25. Volatile Organics
Yes
No
*ALL SAMPLES MUST BE PRE-SCREENED FOR EXPLOSIVES PRIOR TO ENTRY INTO THE PHL*
Page 1 of 2
Attention: (Two page form) DOH 302-019 (07/2016)
State of Washington
Department of Health
PUBLIC HEALTH LABORATORIES
1610 N.E. 150th Street
Shorelin, WA 98155-9701
Phone (206) 418-5400
PHL USE ONLY
Fax (206) 418-5545
:
SAMPLE TRANSFER
. CHAIN OF CUSTODY-
29
(Each person receiving or relinquishing the sample must sign below)
Relinquished Custody
Agency/Organization
Date/Time
Received Custody
Agency/Organization
Date/Time
Print Name:
Print Name:
_____/_____/_____
_____/_____/_____
Signature:
Signature:
_____________ am / pm
___________ am / pm
Print Name:
Print Name:
_____/_____/_____
_____/_____/_____
Signature:
Signature:
_____________ am / pm
___________ am / pm
:
LABORATORY USE ONLY.
INTERNAL SAMPLE TRANSFER
30.
(Each person receiving or accessing the sample must sign below)
Relinquished by
Reason/Amount
Date/Time
Received by
Date/Time
Print Name:
Print Name:
_____/_____/_____
_____/_____/_____
_____________ am / pm
___________ am / pm
Signature:
Signature:
Print Name:
Print Name:
_____/_____/_____
_____/_____/_____
_____________ am / pm
___________ am / pm
Signature:
Signature:
Release or Destruction of Sample(s)
31.
Upon final completion of all testing the submitter will be contacted regarding the release or destruction of the submitted sample(s) stated above. The Washington State
Department of Health Public Health Lab will destroy the submitted sample(s) on behalf of the submitter. If destruction is desired, the submitter must complete the form
below in-person or fax to (206) 418-5445.
Release of all Sample(s) must be picked up in person and cannot be mailed
Relinquished
Agency/Organization
Date/Time
Received Custody
Agency/Organization
Date/Time
Custody
32.
Print Name:
Print Name:
_____/_____/_____
_____/_____/_____
RELEASE
Signature:
___________
_____________
Signature:
am / pm
am / pm
Request from
Agency/Organization
Date/Time
Destroyed by
Agency/Organization
Date/Time
33.
Print Name:
Print Name:
_____/_____/_____
_____/_____/_____
DESTROY
Signature:
Signature:
___________
_____________
am / pm
am / pm
Attention: (Two page form) DOH 302-019 (07/2016)
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