New Mexico Forms Library

9-505.  Report of blood alcohol analysis.

[For use with Magistrate Court Rule 6-607 NMRA,

Metropolitan Court Rule 7-607 NMRA and

Municipal Court Rule 8-603 NMRA]

 

______________________________________________________________________

(Insert name of laboratory)

 

REPORT OF BLOOD ALCOHOL ANALYSIS

Laboratory number:             ________________________

Date received:                      ________________________

Time received:                      ________________________

______________________________________________________________________

______________________________________________________________________

PART A

INFORMATION IN THIS BLOCK TO BE

FILLED IN BY ARRESTING OFFICER

 

SEND LAB ANALYSIS REPORT TO:

Name:            ____________________________

                        (Complete name of your agency)

Address:        _____________________________       __________________________

                        (Street or P.O. box)                                     (City, state and zip code)

______________________________________________________________________

______________________________________________________________________

SEND COPY TO DONOR:

Donor's identification:

Name:            ___________________________________________________________

                        (Last) (first) (middle)

Address:        ___________________________________________________________

                        (Street or post office box number)

            ________________________________________________________________

                        (City, state and zip code)

 

Social security number:      __________________

Driver's license number:     __________________

Date of birth:                         __________________

Sex: ______________        Weight: ____________

______________________________________________________________________

______________________________________________________________________

BLOOD DRAW INFORMATION

Date blood drawn:   __________________

Time blood drawn:   __________________ (a.m.) (p.m.)

Place drawn:             ______________________________

Blood drawn by:

___________________________            ___________________________

Print name                                                     Signature

 

Blood draw witnessed by:

 

___________________________            ___________________________

Print name                                                     Signature

 

Remarks: _____________________________________________________________

______________________________________________________________________

______________________________________________________________________

ARREST INFORMATION

Reason for law enforcement contact:

[ ]         Erratic driving ______________________________

[ ]         Accident: [ ] Fatal [ ] Great bodily injury

            [ ]         (other) ______________________________

[ ]         Other ____________________________________

 

Investigated or witnessed by:

 

___________________________            ___________________________

Print name                                                     Signature

 

Arresting officer's identification:

Department:              _______________________________

Date of arrest:           _______________________________

Place of arrest:          _______________________________

County:                      _______________________________

Arrest time:                _______________________________ (a.m.) (p.m.)

Arresting officer:

___________________________            ___________________________

Print name                                                     Signature

______________________________________________________________________

______________________________________________________________________

INFORMATION BELOW IS TO BE FILLED IN BY DRAWER OF ANY BLOOD SAMPLE

I certify that on the date, time and place indicated above, I drew blood samples from the above named donor and that I marked and sealed the samples with the donor's name.

(For use in implied consent cases)

_________ (initials)  I certify that the blood was collected using the entire contents of a state scientific laboratory division approved blood collection kit in accordance with scientific laboratory division's approved instructions.

___________________________            ___________________________

Signature of blood drawer                          Date

 

___________________________

Title

___________________________

Employer name

______________________________________________________________________

______________________________________________________________________

PART B

 - - - - - - - - - - - - - - - - - - - - - - LABORATORY USE ONLY - - - - - - - - - - - - - - - - - - - - 

CERTIFICATE OF RECEIVING EMPLOYEE

Specimen of [ ] Blood [ ] Other __________

Received from

___________________________            ___________________________

Print name                                                     Signature

 

[ ] In person [ ] via mail [ ] other_______________________________________________________

 

Seal intact: Yes [ ] No [ ]. If No, explain:_______________________________________________________________

______________________________________________________________________

Other Remarks:_________________________________________________________

I certify that on the date shown in the "date received" blank above, I received the sample which accompanied this report and followed the procedures set out on the reverse of this report, and that the statements in this block are correct.

Receiving employee

 

___________________________            ___________________________

Print name                                                     Signature

______________________________________________________________________

______________________________________________________________________

CERTIFICATE OF ANALYST

The seal of this sample was received intact and was broken in the laboratory:

[ ]  Yes 

[ ]  No 

If No, explain: ______________________________________________________________________

 

RESULT OF ANALYSIS

Blood Sample: ______________________________ gms/100 ml alcohol concentration in sample.

REMARKS: ____________________________________________________________

______________________________________________________________________

I certify that I followed the procedures set out on the reverse of this report, and that the statements in this block are correct. The concentration of alcohol in the sample is based on the grams of alcohol in one hundred milliliters of blood.

Date of analysis: ______________________________

 

Analyzed by:

___________________________            ___________________________

Print name of analyst                                  Signature of analyst

 

CERTIFICATE OF REVIEWER

I certify that the analyst who conducted the analysis in this case meets the qualifications required by the director of this laboratory to properly conduct such analyses; the supervisor of analysts is also qualified to conduct such analyses; and that the established procedure has been followed in the handling and analysis of the sample in this case.

_____________________________

Date

 

Reviewer:

___________________________            ___________________________

Print name                                                     Signature

 

CERTIFICATE OF MAILING

I certify that on this date I mailed a legible copy of this report to the donor, in accordance with the mailing procedure set out on the reverse of this report.

___________________, _________

Date

 

Laboratory employee:

___________________________            ___________________________

Print name                                                     Signature

 

PROCEDURE

(To be printed on the reverse side of report)

 

1.         The laboratory named on the front of this report is a laboratory authorized or certified by the scientific laboratory division of the health department to perform blood and alcohol tests. The agency has established formal procedures for receipt, handling and testing of blood samples to assure integrity of the sample, a formal procedure for conduct and report of the chemical analysis of the samples by the gas chromatographic method (__________________) (specify, if other method used) and quality control procedures to validate the analyses. The quality control procedures include semi-annual proficiency testing by an independent agency. The procedures have the general acceptance and approval of the scientific community, including the medical profession, and of the courts, as a means of assuring a chemical analysis of a blood sample that accurately discloses the concentration of alcohol in the blood. The same procedures are applicable for samples other than blood if submitted for alcohol analysis. The analyst who conducts the analysis in this must meet the qualifications required by the director of this laboratory to properly conduct such analyses. The supervisor of analysts must also be qualified to conduct such analyses.

2.         When a blood sample is received at the laboratory, the receiving employee examines the sample container and:

                        (a)       determines that it is a standard container of a kit approved by the director of the laboratory;

                        (b)       determines that the container is accompanied by this report, with Part A completed;

                        (c)        determines that the donor's name and the date that the sample was taken have already been entered on this report and on the container and that they correspond;

                        (d)       makes a log entry of the receipt of the sample and of any irregularity in the condition of the container or its seals;

                        (e)       places a laboratory number and the date of receipt on the log, on the container, and on this report, so that each has the same laboratory number and date of receipt;

                        (f)        completes and signs the Certificate of Receiving Employee, making specific notations as to any unusual circumstances, discrepancies, or irregularities in the condition or handling of the sample up to the time that the container and report are delivered to the analysis laboratory;

                        (g)       personally places the container with this report attached in a designated secure cabinet for the analyst or delivers it to the analyst.

3.         When the blood sample is received by the analyst, the analyst:

                        (a)       makes sure the laboratory number on the container corresponds with the laboratory number on this report;

                        (b)       makes sure the analysis is conducted on the sample which accompanied this report at the time the report was received by the analyst;

                        (c)        conducts a chemical analysis of the sample and enters the results on this report;

                        (d)       retains the sample container and the raw data from the analysis;

                        (e)       completes and signs the Certificate of Analyst, noting any circumstance or condition which might affect the integrity of the sample or otherwise affect the validity of the analysis;

                        (f)        delivers this report to the reviewer.

4.         The reviewer checks the calculations of the analysis, examines this report, signs the Certificate of Reviewer, and delivers the report to a laboratory employee for distribution.

5.         An employee of the agency mails a copy of this report to the donor at the address shown on this report, by depositing it in an outgoing mail container which is maintained in the usual and ordinary course of business of the laboratory. The employee signs the certificate of mailing to the donor, and mails the original of this report to the submitting law enforcement agency.

6.         The biological sample will be retained by the testing laboratory for a period of at least six (6) months pursuant to regulations of the scientific laboratory division.

 

USE NOTES

 

            This form, after appropriate modifications, may also be used for controlled substance and other test reports.

[As amended, effective October 1, 1991; July 1, 1999; November 1, 2004.]