**\[EXAMPLE #1\]**

##### FAA EXTERNAL SPECIMEN CHAIN OF CUSTODY (COC FORM)

1.  Victim Name: [John
    Doe]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Birth
    Date:\_\_[10/20/1954]{.underline}\_\_\_\_\_\_\_\_ SS
    #:\_\_\_[123-45-6789\_]{.underline}\_\_\_\_\_\_

2.  Accident Date:\_[\_7/27/2004\_]{.underline}\_\_\_
    Time:\_\_\_\_[10:00 AM\_]{.underline}\_\_\_\_ Accident
    Location:\_\_[Somewhere, South Dakota\_\_]{.underline}\_\_\_\_\_\_

*Specimen Transfer Documentation*

###  Released By Release Date Release Time Received By

3.  [a Peter Pathologist ***Peter Pathologist***]{.underline} [b
    7/29/2004]{.underline} [c 11:30 AM]{.underline} [d Lara Labtech
    ***Lara Labtech***]{.underline}

4.  [a Lara Labtech ***Lara Labtech***]{.underline} [b
    7/29/2004]{.underline} [c 12:30 PM]{.underline} [d Refrigerator B
    .]{.underline}

5.  [a Refrigerator B]{.underline} [b 7/30/2004]{.underline} [c 1:30
    PM]{.underline} [d Alvin Accessioner ***Alvin Accessioner***
    .]{.underline}

6.  [a Alvin Accessioner ***Alvin Accessioner***]{.underline} [b
    7/30/2004]{.underline} [c 2:30 PM]{.underline} [d FedEx
    .]{.underline}

7.  [a]{.underline} [b]{.underline} [c]{.underline} [d .]{.underline}

8.  [a]{.underline} [b]{.underline} [c]{.underline} [d .]{.underline}

9.  [a]{.underline} [b]{.underline} [c]{.underline} [d .]{.underline}

10. Was black plastic bag sealed with ***Evidence Tape*** upon ***final
    release***? Yes No

11. *One box for the question on line 10 must be checked at final
    release, prior to shipping!!*

*\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--Instructions\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--*

A.  Type or print the victim's name, birth date, SS #, accident date,
    and other known case identifying accident information on lines 1 and
    2 above. Place all specimens in the black plastic bag, seal with
    evidence tape, and place in the TOX BOX.

B.  ***Record all information for "Specimen Transfer Documentation" on
    lines 3 through 9 above. Enter names as described below for full
    accounting of all sample handling. These signatures are crucial for
    the correct documentation of the Chain of Custody on this COC
    Form!!***

C.  The first person [releasing]{.underline} specimens (e.g.,
    Pathologist) will first type/print, and then ***sign*** his/her name
    under the "Re­leased By" column on line 3a. This person will then
    note date and time of [release]{.underline} on lines 3b and 3c,
    respectively.

D.  The first person [receiving]{.underline} specimens (e.g., Lab
    Assistant) types/prints, and then ***signs*** name under the
    "Received By" column on line 3d. This person then
    [later]{.underline} signs, upon release of specimens, under the
    "Released By" column on line 4a.

E.  ***[All]{.underline} persons handling specimens should indicate
    receipt and release in the above manner.***

F.  If the TOX BOX, containing specimens in the sealed black bag, is
    placed into [temporary storage]{.underline}, then person
    [releasing]{.underline} box must note date / time of release
    [to]{.underline} storage. This person should also note storage type
    (e.g., "Refrigerator") under "Received By" and "Released By". Person
    [receiving]{.underline} box must note date / time of receipt
    [from]{.underline} storage.

G.  Person ultimately [releasing]{.underline} specimens to a carrier
    (e.g., Airborne, FedEx, etc.) [must]{.underline} sign under
    "Released By," note date and time of [release]{.underline} to
    carrier, and then write name of carrier [company]{.underline} under
    "Received By" on the same line for which release is documented.

H.  After indicating which carrier is receiving the TOX BOX, the person
    carrying out final specimen release should confirm that the black
    plastic bag is sealed with evidence tape. Document this by checking
    the box on line 10 above.

I.  Place this completed ***External Chain of Custody (COC Form)***,
    along with the Accident Information Form (Page #2), in TOX BOX along
    side the sealed bag. Seal the TOX BOX with black tape provided, and
    then give the box to carrier. [See "Special Instructions" on Page
    #2]{.underline}.

J.  ***Carrier representative should* NOT *personally sign for receipt,
    or for release, of TOX BOX.***

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--For
CAMI Use
Only\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

######## **Received in CAMI Room 351A:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Received by Date Time

Was Evidence sealed upon ***receipt***? Yes No Inspected
By:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Case #, Assigned at receipt by
CAMI:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

AC 8025-8 (10/12/2006) Page 1 of 2

**\[EXAMPLE #2\]**

##### FAA Accident Information

1.  Victim Name:\_ [John
    Doe]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Birth
    Date:\_\_\_[10/20/1954]{.underline}\_\_\_\_\_ SS
    #:\_\_\_[123-45-6789\_]{.underline}\_\_\_\_\_

2.  Accident Date:\_\_\_[7/27/2004]{.underline}\_\_\_
    Time:\_\_\_\_[10:00 AM \_]{.underline}\_\_\_\_ Accident
    Location:\_\_[Somewhere, South Dakota]{.underline} \_\_\_\_\_\_\_

Pilot Co-Pilot Driver Passenger
Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.  Aircraft/Other Vehicle Make & Model: \_[Cessna
    A7Q\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4.  Aircraft N#:\_\_[N
    1234Z\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    NTSB Accident #:\_\_[\_LA
    04FA123\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.  Accident Type: General Aviation Commercial Aviation Agricultural
    Aviation

Highway Marine Rail Other:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  Number of
    Fatalities:\_\_\_\_\_\_[\_3\_\_\_\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7.  Fire Status: Yes No Unknown Fire Status

8.  ME Case Number\_\_\_\_\_\_\_\_\_[SDME
    123\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_N/A

9.  Miscellaneous Information:\_\_\_\_[Crashed on Takeoff, Alcohol
    Suspected. 2 Passengers
    sent.\_\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

10. FAA Representative:\_[Abraham
    Washington\_\_\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Phone:\_[\_\_210-123-4567\_\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

11. NTSB Investigator:\_ [\_George
    Lincoln\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Phone:\_\_\_[777-765-4321]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##### Medical Examiner/Coroner Information

12. Autopsy By:\_[Peter
    Pathologist\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Phone:\_\_[888-123-9876\_\_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

13. Does Medical Examiner/Coroner want a copy of the final Case report ?
    Yes No

14. Form of [signed]{.underline} report requested: [electronic (Adobe
    .pdf file):]{.underline} [paper:]{.underline} N/A

15. Medical Examiner/Coroner e-mail
    address\_\_\_\_[\_ppathologist@me.com]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_[\_\_]{.underline}N/A

16. Mailing
    Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_N/A

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--Special-Instructions\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--***

1\. This Accident Information form may also be faxed to CAMI. Our Fax \#
is 405-954-3705.

2\. For clarification of any items on Pages #1 or #2 of this form please
call: 405-954-4866.

3\. For the latest information update you may also reach the CAMI web
site at the following URL:\
[http://www.cami.jcccb.gov/AAM-600/Toxicology/600FOR.html](http://www.msn.com/)

4\. When you reach this page, click on the "Tox Box" to read about
sample requirements, you will also find a link to our COC forms.

5\. The "Tox Forms" icon will immediately direct you to a command for
printing these forms and all relevant instructions.

6\. Please make sure that our pre-printed shipping label is on the
outside of the box.

**Case #, Assigned at receipt by
CAMI:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

### 

AC 8025-8 (10/12/2006) Page 2 of 2