Attachment A - Sample Forms Specs~1.pdf

Folding Diagram

Envelope attached, overhanging edge

Conviction Information

For Laboratory Use Only

DNA Indexing Database Sample Receipt

ATTACHMENT HH: SAMPLE FORMS

Printing Diagram:

Side 1

DNA INDEXING DATABASE

SAMPLE RECEIPT

Side 2

Voluntary Consent

(3) Collection Date

Instructions for Completing Information Portion of Kit

(8) Conviction Information

Buccal Swab Collection Instructions

Attach Envelope

DNA Indexing Database Buccal Swab Collection Kit

Perforate Here

Score Here

Score Here

Actual Picture shown below on page 10

Vendor Name Vendor Return Address Reorder information

Peal off seal

Backside of Mailing envelope

Barcode of Kit#

Desiccant pack to be inside the swab envelope

Ink strips, labeled Peel Here

Do-over stickers for covering bad thumb prints

Kit shipping seal

STOP

CONSENT TO PROVIDE A VOLUNTARY

DNA SPECIMEN

Voluntary Samples are freely given without obligation and not based on any other Qualifying Reason listed in Section 5 on the front of this Receipt.

Voluntary Sample:

I, ____________________________________, voluntarily consent to provide a buccal swab specimen to the Illinois State Police. I understand scientific information obtained from the swab(s) may be used for criminal investigations and may be retained in a record keeping system for future reference. I voluntarily consent to allow the Illinois State Police to use the swab(s) and the information obtained from the swab(s) for any authorized purpose. I understand that I am free to refuse to provide a buccal swab specimen, but that I voluntarily do so and consent to the terms of this statement.

Signature of Voluntary Donor

Date/Time

Printed Name of Collection Official/Witness

Signature of Collection Official/Witness

If the voluntary donor is a Juvenile, a parent or legal guardian must co-sign this consent form.

Printed Name of Parent or Legal Guardian

Signature of Parent or Legal Guardian

BUCCAL SWAB COLLECTION

INSTRUCTIONS

Prior to collection, check the Offender DNA Database Search site or call or fax the DNA Indexing Laboratory to make sure a sample is not already on fi le.

Phone (217) 786-6160 Fax (217) 786-6956 http://dnaweb.isp.illinois.gov

INSTRUCTIONS FOR COMPLETING

INFORMATION PORTION OF KIT

1) Donor’s Identifying Information: Print donor’s name;

have donor sign. Print date of birth and check race and gender. PRINT CLEARLY. Verify the printed name matches the signature. If they are different, ensure the correct person is being collected and initial the blank indicating that the name difference is acceptable. This is especially important for donors with suffi xes and hyphenated names.

2) Collection Certifi cation: Read and sign stating that you have verifi ed the identity of the donor.

3) Collection Date: Date the sample was collected.

4) Identifi cation Numbers: Enter appropriate identifi cation numbers for the donor.

5) Qualifying Reason: Select the reason why the donor is eligible/required to donate a sample. Enclose a copy of the signed court order for court ordered samples. If the donor is transferring to Illinois from another state, record the other state in the space provided.

6) Agency: The Responsible Agency is the agency in Illinois that is responsible to collect the donor’s sample.

The Collection Agency is the agency conducting the collection on behalf of the Responsible Agency. Please list the complete address, including zip code, of the agency collecting the sample. Include a contact’s name and telephone number. The use of printed address labels is encouraged.

7)

8)

Adjudication / Felony Conviction / Court Order / Registration / Indictment Date Information: Enter date of the adjudication, conviction, court order or sex offender registration, or indictment.

THUMBPRINT: Peel apart the black inked finger-print sheet and place on a flat surface with inked side up.

Roll the donor’s right thumb on the inked sheet from the inside edge of the thumb toward the donor’s body. If the right thumb cannot be printed, the left thumb or another digit may be used. Label print, if not right thumb. Roll the inked thumb on the thumbprint block in the same manner. The print should extend from side to side and from the tip of the finger to just below the first joint. The print should consist of clear, distinct ridges. Let the print dry completely. NOTE: If a clear print is not obtained, affix a white re-tab from the kit over the first print and repeat. SAMPLE WILL NOT BE ACCEPTED WITHOUT A CLEAR THUMBPRINT.If you have any questions, call the Laboratory at (217) 786-6160.

1) Personnel from the Responsible Agency or designee will collect the buccal swabs from the donor.

2) The following collection procedure must be performed on one donor at a time.

3) Read the entire instruction sheet prior to collecting the sample.

4) Do not use the kit if the kit has been opened or damaged.

5) Do not handle the cotton bulb of the swabs.

DNA Indexing Database Buccal Swab Collection Kit

ILLINOIS STATE POLICE

Division of Forensic Services

DNA Indexing Laboratory 3710 East Lake Shore Drive

Springfi eld, IL 62712

(217) 786-6160 (voice) • (217) 786-6956 (fax)

1 (800) 255-3323 (TDD)

DNA2IL(BS):DCC1.5 9/11

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

STEP 7

STEP 8

STEP 9

STEP 10

STEP 11

Fill out all information requested on the DNA Sample Receipt Form and the envelope affi xed to the end of the receipt.

Using the inked strip provided, take a right thumbprint of the donor.

Have the donor remove gum, tobacco, etc.

from mouth.

Put on biohazard barrier gloves.

Open one of the sterile swab packages containing two swabs.

Using the two swabs, vigorously swab the inside of the donor’s cheek at least 6 times.

Remove swabs from the donor’s mouth, completely air dry and replace in the opened sterile swab package.

Open the second sterile swab package containing two swabs and vigorously swab the inside of the donor’s other cheek at least 6 times. Remove swabs from the donor’s mouth, completely air dry and replace in the opened sterile swab package.

Place both swab packages into the Swab Envelope. Remove the backing from the envelope flap and press to seal. DO NOT DETACH the swab envelope from the receipt.

Remove gloves and discard in an appropriate waste receptacle. DO NOT place used gloves in the envelope.

Refold the completed kit and place it into the preprinted return envelope. Remove the backing from the fl ap and press to seal the envelope. Attach the Kit Shipping Seal and initial.

Mail the completed kit.

DNA INDEXING DATABASE

SAMPLE RECEIPT

Laboratory Barcode

(1) Donor’s Identifying Information

PLEASE PRINT CLEARLY

Last Name

First Name MI

Signature of Donor

ATTENTION COLLECTOR: If signed name doesn’t match printed name exactly (e.g. nickname, maiden name, suffi x, or hyphenated name), confi rm correct person is being collected and initial here ___________

Birth Date Mo Day Year

Race (check one) ��Asian ��Black ��Hispanic ��Native American ��White ��Other ______________

Gender (check one) ����Male ��Female

(2) Collection Certifi cation I hereby certify that I have verifi ed the identity of the donor named in section (1) prior to witnessing/performing the DNA collection.

Printed Name of Collection Offi cial

Signature of Collection Offi cial

(7) Adjudication / Felony Conviction/Court Order/

Registration/Indictment Date

Mo Day Year

(8) RIGHT THUMBPRINT

Print is to be taken at the time of swab collection.

Samples will not be accepted without a legible fi ngerprint. Indicate if a different fi nger is used.

(3) Collection Date

Mo Day Year

DNA2IL(BS):DCC2.5 9/11

(4) Identifi cation Numbers

SID # I L

IDOC #

FBI# ________________________________________

Cause/Court # ________________________________

(5) Qualifying Reason(s) (check all that apply)

��Adjudicated of a Felony (Juvenile Court Act) ��Convicted of a Felony (Adult Criminal Code) ��Court Ordered (attach order) ��Court Ordered Misdemeanant (attach order) ��Incarcerated in IDOC or IDJJ ��Interstate Transfer from ____________________ ��Qualifying Indictee ��Sex Offender Registrant (includes SDP/SVP) ��Voluntary (must complete consent form on back)

(6) Agency (please print clearly or use a label)

Responsible Illinois Agency Collection Agency Name (if not the Responsible Illinois Agency)

Street Address City State Zip Telephone Number Contact Name

2 0

For Laboratory Use Only

2 0

For Laboratory Use Only

For Latents Use Only

Right Thumbprint

Barcode goes here

Envelope - Maximum 3.25"

Envelope - maximum 8"

Label or printed

Envelope should overhang off edge of receipt form

Perforated edge

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Pre-printed addressed return envelope with business reply mail Mark Up (Section 1.2.A.1 of contract) - Actual photo on Page 11 below

Actual Photograph of the Acordian Folded Printing Diagram shown on Page 2 above

Actual photograph of Pre-Printed addressed return envelope with business reply (Section 1.2.A.1 of contract)