U.S. DOD Form dod-da-1971-6-r
Chemical/Biological Sample Documentation
For use of this form, see FM-3; the proponent agency is TRADOC
INSTRUCTIONS
Place the biological sample inside a refrigerator, ice chest, or insulated container; and keep it as cool as
possible at all times.
Sample Identification Number:
Date and Time Sample Collected:
Reason for Collection
(check those that apply):
Chem/Bio Attack
Chem/Bio Alarm Activated
Positive M256 Chemical Detection
Positive Recon Team Findings
Soldiers Becoming Sick
Soldiers Dying
Other
Location of Attack
(UTM or place)
Unit Identification
Date and Time of Attack
(Co, Bn, Bde, Div, Corps)
Terrain Description (check those that apply):
Flat
Hills
Urban
Mountains
Desert
Sparse Trees/Shrubs
Grassy
Forest
Jungle
Other
Weather (check those that apply):
Clear
Cloudy
Rain
Snow
Fog
Dust
Mist
Other
Wind at Collection Site (check only one):
None/Calm
Mild Breeze
Gusts
Windy
Odor (check those that apply):
None
Sweet
Changing
Fruity
Irritating
Pepper
Flower
Other
Symptons (check those that apply):
None
Skin Swelling
Difficulty Breathing
Blurred Vision
Dizziness
Skin Rash
Nausea
Dry Mouth
Fever
Dark Skin Blotches
Headache
Bleeding Sores
Unconscious
Other
Symptoms:
Time of Onset:
DA FORM 1971-6-R, OCT 92
Duration (of Symptoms):
USAPPC V1.00
Delivery Method (check those that apply):
Unknown
Artillery
Aircraft
Mortar
Generator
Aerosol
RPG/Grenade
Rocket
Other
State of Agent at Time of Collection (check only one):
Liquid
Vapor
Dust (cloud)
Gel
Powder
Solid
Smoke
Mist
Other
Description of Sample (check only one):
Biomedical:
Vegetation
Soil
Other
Urine
Blood
Tissue
Color of Sample
Size of Sample
Other
Additional Remarks:
REVERSE OF DA FORM 1971-6-R, OCT 92
USAPPC V1.00