BLOOD SAMPLE AUTHENTICATION FORM
Forensic Science Laboratory
Director, Forensic science laboratory
Government of West Bengal
37/1/2, Belgachia Road, Kolkata-700037
A. Particulars of donor:
i) Name (In BLOCK letters):
ii) Father/ Guardian’s Name: Affix passport
iii) Sex: iv) Date of Birth: sixe
photograph of
v) Address: the donor
attested by
vi) Medical History:
Medical Officer
Normal: Chronic Disease: Genetic Disorder:
Vii): Blood Transfusion, if any, in past three months:
viii) Organ Transplantation, if any:
B. Case Details
Case No. Date: PS.: u/s:
C. Purpose for conducting test:
D. Declaration by the Blood Donor/ Guardian (in case of minor) :
I .............................................. hereby certify that the blood sample is being collected with my consent and
acknowledge the above information to be true.
Signature of Donor:
Name:
Date
Left thumb impression Right thumb impression
E. Sample Collection: Preferably 2/3 ml. Blood should be collected in vacutainer or on FTA Cards or sterilized tube
using EDTA as anticoagulant. The tubes should be duly preserved in an ice container for transport. Alternatively, blood
sample may be dried on clean sterilised gauze / filter paper and sealed in paper envelope.
i) Nature of sample. Liquid Blood/Blood stains ii) Date of collection: iii) Volume
Seal Collected by
Impression
Sealing Wax
Signature, Name & Designation of Medical Officer with stamp.
F. Collection procedure witnessed by:
Witness: Witness:
Signature: Signature:
Name: Name:
Designation: Designation:
Address: Address:
Date: Date :
SEXUAL ASSAULT VICTIM INFORMATION FORM
Forensic Science Laboratory
Director, Forensic science laboratory
Government of West Bengal
37/1/2, Belgachia Road, Kolkata-700037
(To be completed by the Authorized Medical Officer who conducted the Medical Examination)
1. Victim Name: ....................... ........................ ........... MLR/PMR No ....................... Attested
Address: ........................................................................ Age: ............ Sex: .............. Photograph
By Medical
Date & Time of assault: ............................ District & State of Incident: ....................... Officer
Date of Examination: .............................
Number of Assailants: ...................................................... Age: ............... Sex: .........
Sexual assault Examiner:
Hospital Name:......................................................... Hospital Telephone No:...................
2. DETAILS OF ASSAULT: (e.g. oral, rectal, vaginal penetration/contact: perpetrator penetration of victim with fingers
or with foreign object; oral contact by perpetrator; oral contact by victim; ejaculation, if known by victim, other
injuries).
3. Pregnancy test to determine pre-existing pregnancy only: Yes/No/Don’t know:......................
4. PRIOR TO EVIDENCE COLLECTION, VICTIM HAS:
1. Bathed/Urinated/Defecated/Vomited/Had Food or Drink/Brushed Teeth of Used Mouthwash.................
None of the above.............
2. Whether clothes changed: Yes/No/Don’t know:......................
3. For “Rape Drug’ test blood and /or Urine sample taken: Yes/No/Don’t know:......................
5. AT TIME OF ASSAULT WAS:
1. Contraceptives/spermicide/Lubricant/Condom present/used ? Yes/No/Don’t know:......................
2. Victim menstruation? Yes/No/Don’t know:......................
6. AT TIME OF EXAM WAS: victim menstruating: Yes/No/Don’t know:......................
7. RECENT OF CONSENSUAL COITUS:
Has victim had consensual coitus within last 5 days? Yes/No/Don’t know:......................
If yes, was birth control used? Yes/No/Don’t know:......................
What method of birth control was used: ........................................
Brief Description of Evidence Submitted (one item per line.)
Parcel No. No. of Seals Description
Chain of Custody
Evidence received
Evidence delivered to Date comments
Parcel Description from
Examinations Requested
Person authorizing release of Information is (check one): Victim..........Victim’s parent..........Victim’s
guardian...........other (specify).............
If reporting anonymously, I have been informed that all evidence, including my clothing will be disposed of, if I do not
report the crime within 3 months after the medical examination.
Signature: Date:
VICTIM/PARENT/GUARDIAN SIGNATURE Places:
Signature with stamp: Date:
SEXUAL Assault Examiner Places:
ABORTUS (ABORTED FOETUS) IDENTIFICATION SHEET
(DNA PATERNITY TESTING)
Forensic Science Laboratory
Director, Forensic science laboratory
Government of West Bengal
37/1/2, Belgachia Road, Kolkata-700037
(To be completed by the Authorized Medical Officer who conducted the Medical/Postmortem Examination)
1. Identity of person whom abortus sample is being collected:
Name of person: ........................................................................................................
Address: .....................................................................................................................
Where the individual is juvenile or deceased ? .........................................................
2. Specimen Collection (See instructions):
Hospital Name: ................................................. Hospital Telephone No. ..................
Medical Examiner: ...................................................................... Date: .....................
3. Type of Specimen(s) Collected (please specify the portion of Abortus)
i.
ii.
iii.
4. Weeks Gestation: .................................... Storage conditions used ..........................
5. Chain of Custody:
Specimen sealed and released by: ............................................................................
Specimen released to: ...............................................................................................
Mode of release: Hand delivery.............................. Mail..........................................
Date sent to FSL, Kolkata:
Signature of Authorized Medical Officer:
ABORTUS SPECIMEN COLLECTION INSTRUCTIONS :
Abortus collection Wear gloves while collecting samples.
Tissue from an abortus shall be selected by the physician and approximately 2 cm portion must be placed into
a sterile plastic tube.
Print the mother’s name and the date of collection on the label.
Physician should put his/her initials on the label.
Storage Don’t preserve the tissue in formalin.
Freeze the tissue and transport it on ice.
Blood sample should be collected in sterile EDTA tubes. Do not freeze the blood sample
Forms Complete the forms, documenting all the required information.
Sign the form where indicated to verify collecting the biological samples
Packing Package each sample separately and affix with a tamper proof seal.
AUTOPSY SPECIMEN (S) SUBMISSION FORM
Forensic Science Laboratory
Director, Forensic science laboratory
Government of West Bengal
37/1/2, Belgachia Road, Kolkata-700037
(To be completed by the Authorized Medical Officer who conducted the Postmortem)
1. Identity of person whom abortus sample is being collected:
Name: ............................................................. Religion/Caste: .................................
Date of Death: .......................... Hospital Patient # (if any)........................................
2. Cause of Death: .....................................................
3. Has the individual received a blood transfusion or bone marrow transplant in the last three
months:
4. Legal contact: ....................................................... Phone: .........................................
5. Specimen Collection:
Collection Centre Name: ............................................................................................
Collection Centre Address: .........................................................................................
Sample Collected by: ..........................................Sample collection Date: ................
6. Description of Samples Collected:
Sample Storage conditions Other remarks
Note: If the disposal or return of the sample is not authorized, a specimen(s) may be destroyed of in
1 year.
7. Chain of Custody
Specimen(s) sealed and released by: ..........................................................................
Specimen(s) released to: .............................................................................................
Mode of release: Hand delivery................................ Mail...........................................
Date sent to FSL, Kolkata..............................................................................................
Authorized Medical Officer Signature:............................................. Date: ...................
