<p> 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 </p><p>Additional Evidence Resubmission DPS Laboratory Use Only DPS Lab Case #/Date Evidence Received Lab Case # (if known) </p><p>Agency Agency Case # Drop Box Mail/Certified Other </p><p>Offense Offense Offense Date Time Printed Name Agency Offense County </p><p>Case Contact Person Information </p><p>Title/Full Name Badge Number </p><p>Physical Address Phone Fax </p><p>City, State, Zip Email </p><p>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 #</p><p>Living Deceased Driver Non-Driver Driver under 21 Driving Commercial Vehicle</p><p>Fatality Incident (other than Suspect) Child Passenger(s)</p><p>Blood Urine Comments </p><p>Collection Date Time Printed Name of Collector Title</p><p>Collection Facility Additional Case Information Intoxilyzer Results: List Drug(s) Suspected: PBT Result: </p><p>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</p><p>Agency Agency Case # </p><p></p><p>Page 2 of 2</p>