DPS Laboratory Use Only DPS Laboratory Case #
Submission Method In Person Drop Box Mail/Certified
Other
Printed Name	Agency
Signature	Date

Submitting Information
Name
Title
Facility
Mailing Address
City, State, Zip
Phone
Email
Assault Information
Date of Assault
County of Assault
Survivor Unique Identifier
Sex	Date of Birth

Evidence Information

Collection Date
Collection Time
Evidence Items Collected:
Sexual Assault Evidence Collection Kit (may NOT contain blood or urine samples)
Survivor Reference Buccal Swab (may be contained within the sexual assault evidence collection kit)
Survivor Clothing
List clothing items collected:

Instructions for Submission

Package all collected evidence items into a single properly sealed evidence box.

Complete this form.

Ensure the survivor’s unique identifier is clearly marked on all evidence packages and forms.

Seal form (LAB-205) in an envelope and attach to the exterior of the evidence box.

Ship the sealed evidence box to:

Texas DPS Bio-Warehouse

12230 West Road, Building C

Houston, Texas 77065