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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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