General Hospital • Operating Theatre

Specimen Chain-of-Custody Log

Specimen Identification

Container # Exact Specimen Description & Site (as labeled) Fixative / State Label Verified By (Initials)
1
2
3
4
5

* Note: All specimen labels must contain at least two patient identifiers and exact site description per .

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Custody Transfer Log (Signatures Required)

Date Time Relinquished By
(Print Name & Sign)		 Received By
(Print Name & Sign)		 Destination / Lab Container Status
(Intact/Sealed)