Toxicology/Blood Alcohol Kit Laboratory Submission Form

TEXAS DEPARTMENT OF PUBLIC SAFETY CRIME LABORATORY Toxicology/Blood Alcohol Kit Laboratory Submission Form LAB-12 Rev.03 (09/2013) p.1 Issued by: QAC

Additional Evidence Resubmission DPS Laboratory Use Only DPS Lab Case #/Date Evidence Received Lab Case # (if known)

Agency Agency Case # Drop Box Mail/Certified Other

Offense Offense Offense Date Time Printed Name Agency Offense County

Case Contact Person Information

Title/Full Name Badge Number

Physical Address Phone Fax

City, State, Zip Email

Exam Alcohol/Volatile Analysis Only Drug Analysis Only Both Alcohol/Volatile and Drug Analysis Requested (Submit to Lab for your Service Area) (Submit to Austin Lab) (Submit to Lab for your Service Area) Specimen Taken From (S=Suspect, V=Victim) S / V Name (Last, First, Middle) Race Sex DOB State Driver License # State ID #

Living Deceased Driver Non-Driver Driver under 21 Driving Commercial Vehicle

Fatality Incident (other than Suspect) Child Passenger(s)

Blood Urine Comments

Collection Date Time Printed Name of Collector Title

Collection Facility Additional Case Information Intoxilyzer Results: List Drug(s) Suspected: PBT Result:

DRE (Drug Recognition Expert) Exam Administered Case Synopsis (attach or include any other relevant case information): TEXAS DEPARTMENT OF PUBLIC SAFETY CRIME LABORATORY DPS Lab Case # Date Evidence Rec’d Toxicology/Blood Alcohol Kit Laboratory Submission Form (Continuation) DPS Laboratory Use Only LAB-12C Rev.02 (05/2013) p.1 Issued by: QAC

Agency Agency Case #