EVIDENCE EXAMINATION REQUEST AND RECEIPT

SUBMITTING AGENCY:	LOCATION (CITY/COUNTY):	SUSPECT(S): 1.	DOB
AGENCY CASE #:	DATE OF OCCURRENCE:	2.	DOB
SUPPLEMENTAL SUBMISSION TO FSL CASE #:	SIMPLE POSS.	FEDERAL	3.	DOB
ARRESTING OFFICER:	CHARGE:	4.	DOB
INVESTIGATING OFFICER:	PHONE, FAX, or E-MAIL:	VICTIM(S)/DECEDENT(S):	DOB
FSL ITEM #	DESCRIPTION OF EACH ITEM SUBMITTED	REQUEST

THIS BOX MUST BE COMPLETED FOR DUI CASES
SUSPECT’S ADDRESS:
TIME OF APPREHENSION:	MEDICAL PERSON COLLECTING SAMPLE:	MEDICAL PERSON’S PLACE OF EMPLOYMENT:
RHODE ISLAND STATE POLICE ONLY – MAIL DUI REPORT TO:
PROSECUTION OFFICER:	BARRACKS:
ADDRESS:

LABORATORY DATE/TIME	GROSS WEIGHT (g)	By submitting your evidence, you agree to the simplified report format posted on the laboratory’s Notice to Submitters. If you would like a copy of this Notice, please request it from evidence receiving personnel.
[FOR LABORATORY USE ONLY]	SUBMITTED BY (PRINT NAME)
SUBMITTED BY (SIGNATURE)
I ACKNOWLEDGE RECEIPT OF THE EVIDENCE, DESCRIBED ABOVE, AS PURPORTED TO BE. ANALYTICAL REQUESTS ARE SUBJECT TO REVIEW. RECEIVED BY (SIGNATURE OF AUTHORIZED LABORATORY PERSON)