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|Donor Last Name: |
| |
|Collection Date: |
| |Drug/Alcohol Screen Result Form |
|Section I: Company & Collector |
|Company: |Address: |
|City: |State: |Zip Code: |
|Phone: |Fax: |Collector: |
|Section II: Donor |
|Name: |Soc. Sec. # |
|Photo ID Type: |Photo ID #: |Phone: |
| |
|Have you taken any prescription or over-the-counter medication in the last three months? θ Yes θ No |
| |
|If yes, please list medication(s) here: _________________________________________________________________ |
| |
|Additional Notes: _________________________________________________________________________________ |
|Section III: Preliminary Results |
|Note: Preliminary positive results may be confirmed via laboratory testing. |
|Specimen temperature within 90-100° F range? θ Yes θ No Notes:__________________________________ |
|Code |Substance |Negative |Preliminary Positive |Not Tested |
|mAMP |Methamphetamine |θ |θ |θ |
|COC |Cocaine |θ |θ |θ |
|THC |Marijuana |θ |θ |θ |
|AMP |Amphetamine |θ |θ |θ |
|OPI |Opiates |θ |θ |θ |
|OXY |Oxycodone |θ |θ |θ |
|MTD |Methadone |θ |θ |θ |
|BZO |Benzodiazepine |θ |θ |θ |
|BAR |Barbiturates |θ |θ |θ |
|MDMA |Methylenedioxymethamphetamine |θ |θ |θ |
|PCP |Phencyclidene |θ |θ |θ |
|BUP |Buprenorphine |θ |θ |θ |
|TCA |Tricyclic Antidepressants |θ |θ |θ |
| |
|ALC |Alcohol |Level: |θ |θ |θ |
|Section IV: Confirmation & Agreement |
| |
|Donor: I agree and grant permission for the specimen I provided to be tested for drug metabolites and/or alcohol. I attest and confirm that the provided specimen |
|is my own, is a fresh specimen that I provided on the premises, and not one that was from a previous collection. I attest the specimen has not been substituted, |
|contaminated, or altered in any way and that all of the information provided by me in relation to this screening is true, complete, and correct to the best of my |
|knowledge. |
|Signature of Donor: ________________________________________ Date: ________________________ |
| |
|Collector: I attest and confirm that the specimen provided by the donor listed above was collected by me and was not substituted, contaminated, or altered in any |
|way to the best of my knowledge. By my observation, the appearance and temperature of the specimen provided were normal and within the acceptable range. I agree |
|that all of the information provided by me in relation to this screening is true, complete, and correct to the best of my knowledge. |
| |
|Signature of Collector: ______________________________________ Date: ________________________ |
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Last Name: First Name:
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