Form DPS-0009-C "Request for Examination of Specimens for Alcohol/Drugs" - Connecticut

What Is Form DPS-0009-C?

This is a legal form that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Connecticut Department of Emergency Services and Public Protection;
  • 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 fillable version of Form DPS-0009-C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Emergency Services and Public Protection.

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Download Form DPS-0009-C "Request for Examination of Specimens for Alcohol/Drugs" - Connecticut

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STATE OF CONNECTICUT
FOR LABORATORY USE ONLY
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
Case Bar Code Label
DIVISION OF SCIENTIFIC SERVICES
278 COLONY STREET, MERIDEN CT 06451
(203) 639-6400 MAIN, (203) 639-6484 FAX, CT.ForensicLab@ct.gov
REQUEST FOR EXAMINATION OF SPECIMENS FOR ALCOHOL/DRUGS
PLACE THE COMPLETED FORM(S) IN THE MAILING SLEEVE AND ATTACH THE SLEEVE TO THE OUTSIDE OF THE
EVIDENCE BOX, PLEASE FOLD THE FORM SO SUBJECT INFORMATION IS NOT VISIBLE
***See Collection & Submission procedure on back of form***
Law Enforcement Agency/Department: _____________________________________________
Agency Case # : _________________
____
Town of Incident:___ _______________________________
Incident Type:
Source:
Driver
/ Passenger
/
Other
(Select all that apply)
DUI /
*
MVA
/
Fatality*
Please include deceased name on RFA for Fatalities
DOB: _____________
Sex: M
/
F
Name of Subject: ____________________________________
Last)
(First
Address of subject:_____________________________________________________________________
(City and State)
(Zip Code)
(Street)
Note: If collecting a urine sample following a breath alcohol test, collect only one urine sample.
If collecting only urine, collect two samples, at least 20 minutes apart .
/
No
(If yes please fill in below)
Breath sample taken? Yes
___ Date/Time: ___
Result 1 (if taken): ____
_____
___ Date/Time: ___
Result 2 (if taken): ____
_____
Specimen # 1
Specimen # 2 (If collected)
Collected By: ____________________________
Collected By: ____________________________
Sealed By: ______________________________
Sealed By: ______________________________
Date/Time Taken: ________________________
Date/Time Taken: ________________________
Specimen Type: Urine / Blood / Other
Specimen Type: Urine / Blood / Other
Subject Consent to Official Request for Sample Collection (blood samples only):
I, ________________________ _____ give consent for the collection of blood samples, as indicated by my
(Print Subject Name)
signature: _____________________________________ Date: ____________
Drugs Suspected (If Any); __________________________________________________________________
__________________________________________________________________
Note: Please fill out & submit to court an appropriate JD-CR-Form for the evidence destruction upon adjudication.
DPS-0009-C Form: revised 10/1/2018
STATE OF CONNECTICUT
FOR LABORATORY USE ONLY
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
Case Bar Code Label
DIVISION OF SCIENTIFIC SERVICES
278 COLONY STREET, MERIDEN CT 06451
(203) 639-6400 MAIN, (203) 639-6484 FAX, CT.ForensicLab@ct.gov
REQUEST FOR EXAMINATION OF SPECIMENS FOR ALCOHOL/DRUGS
PLACE THE COMPLETED FORM(S) IN THE MAILING SLEEVE AND ATTACH THE SLEEVE TO THE OUTSIDE OF THE
EVIDENCE BOX, PLEASE FOLD THE FORM SO SUBJECT INFORMATION IS NOT VISIBLE
***See Collection & Submission procedure on back of form***
Law Enforcement Agency/Department: _____________________________________________
Agency Case # : _________________
____
Town of Incident:___ _______________________________
Incident Type:
Source:
Driver
/ Passenger
/
Other
(Select all that apply)
DUI /
*
MVA
/
Fatality*
Please include deceased name on RFA for Fatalities
DOB: _____________
Sex: M
/
F
Name of Subject: ____________________________________
Last)
(First
Address of subject:_____________________________________________________________________
(City and State)
(Zip Code)
(Street)
Note: If collecting a urine sample following a breath alcohol test, collect only one urine sample.
If collecting only urine, collect two samples, at least 20 minutes apart .
/
No
(If yes please fill in below)
Breath sample taken? Yes
___ Date/Time: ___
Result 1 (if taken): ____
_____
___ Date/Time: ___
Result 2 (if taken): ____
_____
Specimen # 1
Specimen # 2 (If collected)
Collected By: ____________________________
Collected By: ____________________________
Sealed By: ______________________________
Sealed By: ______________________________
Date/Time Taken: ________________________
Date/Time Taken: ________________________
Specimen Type: Urine / Blood / Other
Specimen Type: Urine / Blood / Other
Subject Consent to Official Request for Sample Collection (blood samples only):
I, ________________________ _____ give consent for the collection of blood samples, as indicated by my
(Print Subject Name)
signature: _____________________________________ Date: ____________
Drugs Suspected (If Any); __________________________________________________________________
__________________________________________________________________
Note: Please fill out & submit to court an appropriate JD-CR-Form for the evidence destruction upon adjudication.
DPS-0009-C Form: revised 10/1/2018
Collec on & Submission Procedure
*Note
: When hand delivering, specimens may be contained within a tamper evident sealed plastic bag. Add
agency name & case # to outside of packaging. Forms do not need to be enclosed in red document sleeve.
Urine Kit
1. Complete both lab forms, Request for Analysis (RFA)
.
SOP ER-02:1
) & DPS-0009-C
)
Rev 3 (01/01/2017
Rev (10/1/2018
2. Fill in all fields of red "SECURITY SEAL" (add agency case number).
3. Fill in first Specimen cup label completely (indicate cup #1). Collect sample, add collection time to label, seal
with red seal, DO NOT cover cup label.
4. Wait (20) minutes or more to collect second sample (if needed), label & seal as above. (cup #2)
5.
Fill in “Specimen #1” & “Specimen #2” boxes on form (if applicable) .
6.
Place specimen cup(s) in plastic evidence bag, seal bag.
7. Place specimen bag in cardboard box, seal outside of box with red
“INTEGRITY SEAL", initial & date seal.
Blood Kit
1. Complete both lab forms; (Request for Analysis (RFA)
SOP ER-02:1
) & DPS-0009-C
).
Rev 3 (01/01/2017
Rev (10/1/2018
2. Subject should sign & date form in “SUBJECT CONSENT” section.
3. Fill in all fields of white "SECURITY SEAL" (add agency case number).
4. Draw the first blood sample. Add the date and time of the blood draw to the "SECURITY SEAL" & affix to the
tube, place it across the top of the tube. (indicate specimen #)
5. Second sample should be drawn (20) minutes or more after the first. Label & seal as above.
6. Fill in “Specimen #1” & “Specimen #2” boxes on form (if applicable).
7. Place blood vial(s) in plastic evidence bag, seal bag.
8. Place specimen bag in cardboard box, seal outside of box with red
“INTEGRITY SEAL", initial & date seal.
Submission Procedure
1. Place both completed forms Request for Analysis
SOP ER-02:1 Rev 3
in red document sleeve folded so
(01/01/2017) & DPS-0009-C Rev (10/1/2018)
information is not visible.
OUTSIDE
2. Attach the shipping sleeve to
of the evidence box.
3. Add agency name and case number to
outside of box.
4. Hand deliver specimen(s), Certified mail,
or other trackable method to:
Division of Scientific Services
278 Colony St, Meriden CT 06451
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