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(âîäû, ïðîäîâîëüñòâèÿ)
1 Ëàáîðàòîðèÿ, ïðîèçâîäèâøàÿ èññëåäîâàíèå, ______________
(íàèìåíîâàíèå ÷àñòè,
______________________________________________________
ó÷ðåæäåíèÿ, ìåñòî äèñëîêàöèè)
2 Öåëü ëàáîðàòîðíûõ èññëåäîâàíèé ______________________
3 Âîèíñêàÿ ÷àñòü (ñîåäèíåíèå), íàïðàâèâøàÿ ïðîáó â ëàáîðàòîðèþ,_____________________________________________________
4 Íàèìåíîâàíèå ïðîäóêòà è åãî êîëè÷åñòâî; îáúåêò, ìåñòî è âðåìÿ îòáîðà ïðîáû; ¹ ïðîáû ________________________________
5 Âåñ (îáúåì) ïðîáû ____________________________________
6 Äàòà è âðåìÿ ïîëó÷åíèÿ ïðîáû ëàáîðàòîðèåé _____________
7 Õàðàêòåðèñòèêà õèìè÷åñêîãî î÷àãà çàðàæåíèÿ (äàòà, âðåìÿ, ïðèçíàêè ïðèìåíåíèÿ áîåâûõ òîêñè÷åñêèõ âåùåñòâ, íàëè÷èå ïîðàæåííûõ è äð.), ñîñòîÿíèå ïèùåâîãî îáúåêòà (èñòî÷íèêà âîäû) è ðåçóëüòàòû õèìè÷åñêîé ðàçâåäêè íà îáúåêòå______________________
______________________________________________________
8 Ðåçóëüòàòû ïðåäâàðèòåëüíîãî õèìè÷åñêîãî êîíòðîëÿ ïðîáû ____________________________________________________
9 Ðåçóëüòàòû ëàáîðàòîðíûõ èññëåäîâàíèé
õèìè÷åñêîãî àíàëèçà__________________________________
(âèä òèï îáðàçåö è êîëè÷åñòâî
_______________________________________________________
òîêñè÷åñêèõ õèìè÷åñêèõ âåùåñòâ â ïðîáå)
áèîõèìè÷åñêîãî àíàëèçà _________________________________
10 Ðåçóëüòàòû òîêñèêîëîãè÷åñêèõ èññëåäîâàíèé
áèîëîãè÷åñêèõ__________________________________________
êëèíè÷åñêèõ___________________________________________
ïàòîëîãîàíàòîìè÷åñêèõ__________________________________
11 Çàêëþ÷åíèå__________________________________________
Íà÷àëüíèê ëàáîðàòîðèè _________________________________
(âîéñêîâàÿ ÷àñòü, ó÷ðåæäåíèå, âîèíñêîå çâàíèå
______________________________________________________
Ô.È.Î.)
Âðà÷-òîêñèêîëîã________________________________
(âîèíñêîå çâàíèå, Ô.È.Î. ___________________________
)
Äàòà
Ïå÷àòü