Drug testing chain of custody form, FDNY, Feb 2002

NYC 9/11 Public Portal Document I ' ........... FDNY ENSC St 21/B 14 Fax:F'18-^b-92bf' l-eo 12 -02 T

BENDINER A SCHLESINGER, INC FORENSIC TOXICOLOGY DEPARTMENT THIRD AV^UE AND TENTH STREET * NEW YORK. NY 10003 TEL(312)36WI11 FAX (213) 59WB07

DRUG TESTING CUSTODY ANO CONTROL FORM ■ (CHAIN OF CUSTODY FORM)

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RRST initial iooAsocsec« DEMTIFICATION NUMBER 3. MEDICAL REVIEW OFFICER NAME ANO ADDRESS

ANY MEDICATIONS TAKEN? d YES □ NO IF YES. PLEASE LIST

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))aB,aoMnPinal 1 , L Udna Dnjg Sextan Panel 2 ,,UOdnaDrugScrtanPenal S □ UHm Drug Seraan Pant) a ' ■■ WDA S 'i,' Arnpbaitmlnt. Baibllurala, Amphtaniins. BamunMa. Amphttatnint, CannaMneUi. " Cocaine. Mamaoona, (MaXsa. a I. Cecaana, i.v n Cocall*. OpIMta. Phenejdidna ’ Ptw«*cA«w. MfihadM, Opijuas, PhanCyOdina.

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I COMKLf IfO SECTION R * fScc Copy -7 oA Form}

I ■ a Asova} I DATE OF COLLKTION

BAluiaacoccnweii odLLEcnoatl I collection kfTE PKONENiAlflEfl I AREA COPE (_________ i_____________ __ ________ ____________ ___

r«quSts Iha certDIotaon tn Ccpy 3 e( iMt term, wai * bean iha tame ia«nitteau«i numbai at Ml tai lend inOTKWHBtf I nu ww oqho !S^S£ffSiTaSSSS M, I I 4 M Mica t> m SmtSSbZJ n woMoanoe wt» ap|S*eaBiB L t 1 FD B Y a. SEE SECTION 6 BELOW OR ANO COMPLL ILO AS NFCFSSAHY THtHtAFTFA

Tsna RELEASED BY-Signtlufa-Prt« Name RECEIVED BY-EignBlura-Prim Nams PURPOSE OF CHANGE

SSSb -donor- PnwKjt Specimen lor TeWing

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I’AWO ACCESSIONED A,‘ LABORATORY BOTTLE SEAL INTACT? □ YES □ NO HlFTtD DY Fr.lPlbYLe OR APPLICANT PHOViniNC. RPECiMFN

a. C ONOR SHALL COMPLETE INFORMATION IN SECTION 8 OF COPY 3 (PINK) ” —' ■■ ■■' lokrTiME PHONE NUMBER O*TE OF BIRTH NAME (atl Am mioae)

CCK^FICATION; I cenity' iM I provided my urine tpaciiMri Io ihe collMMr. #»i iho specimen boUe was Mtled witfi a lamper-piool seal in my pretence; and that ine on.'WWi'Med on iMt form ar 3 on Iha label anixed Io ihe specimen botUe Ie correct

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OF THE RORM, TAKE YOUR COPT WITH YOU.

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