Nevada Administrative Code
Chapter 50 - Witnesses
Section 50.015 - Form of declaration regarding presence, identity or amount of alcohol, controlled substance, chemical, poison, organic solvent or other prohibited substance in blood or urine of person

1. If the sample or substance contained a controlled substance as defined in chapter 453 of NRS or a chemical, poison, organic solvent or another prohibited substance:

I, ..........................................., hereby declare:

That I am ................ (occupation) employed by ................ (employer);

That on ......................... (date) I first qualified in the ................ Court of ................ County, Nevada, a court of record, as an expert witness for the purpose of testifying regarding the presence and identity in the blood or urine of a person of a controlled substance the use or possession of which is regulated by chapter 453 of NRS or a chemical, poison, organic solvent or another prohibited substance, or the identity of a controlled substance alleged to have been in the possession of a person;

That on ......................... (date) I obtained certain evidence from ................ (person, or evidence vault in sealed container), the evidence bearing Identification No. ..... of ................ (agency) and consisting of ................ for the purpose of performing a chemical analysis on the contents thereof;

That on ......................... (date) I analyzed the sample or substance and determined it to be or contain ................ (name of controlled substance, chemical, poison, organic solvent or another prohibited substance);

That on ......................... (date) I replaced the sample or substance in its container and sealed the container with a seal bearing my initials .....;

That the evidence was in my sole custody or control from the time I obtained it until I resealed its container, at which time it was in substantially the same condition as when I first obtained it; and

That on ......................... (date) I returned the evidence to ................ (person or evidence vault) or that I still have the evidence in my possession.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on ......................................... .............................................................................

(Date) (Declarant's Signature)

.............................................................................

(Declarant's Title)

2. If the sample contained alcohol:

I, .........................................., hereby declare:

That I am ................ (occupation) employed by ................ (employer);

That on ......................... (date) I first qualified in the ................ Court of ................ County, Nevada, a court of record, as an expert witness for the purpose of testifying regarding the presence and amount of alcohol in the blood or urine of a person;

That on ......................... (date) I obtained evidence from ................ (person, or evidence vault in sealed container), the evidence bearing Identification No. ..... of ................ (agency) and consisting of a sample of ........ (blood or urine);

That on ......................... (date) I analyzed the sample and determined that the blood of the person from whom the sample was taken contained a concentration of alcohol of ..... (grams per 100 milliliters of blood);

That on ......................... (date) I replaced the sample in its container and sealed the container with a seal bearing my initials .....;

That the evidence was in my sole custody or control from the time I first obtained it until I resealed its container, at which time it was in substantially the same condition as when I first obtained it; and

That on ......................... (date) I returned the evidence to ................ (person or evidence vault) or that I still have the evidence in my possession.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on ......................................... .............................................................................

(Date) (Declarant's Signature)

.............................................................................

(Declarant's Title)