Offical Drug Screen Report Forms

Drug Screen Report Form

Specimen ID #__________________ Collection Test Date_____________________

Company Information: (Company giving the test)

Company___________________________________________________________________________________________________ Address____________________________________________________________________________________________________ City______________________ State________________ Zip Code_____________________________________________________

Collectors NOambjee_c_t_i_v_e_________________________ Phone_________________________________________________________ Specimen TEemxppeerraiteunrec(e90-100 F) Within Limits? Y / N Other__________________ Fax__________________________________ Donor Information: (Person being tested)

Donor's Name__________________________________________ SSN_________________________________________________ ID #: ______________________________ ID Type: _________________ Expiration #: ____________________________________ Notes______________________________________________________________________________________________________

Certification Information: (Signatures of both parties required)

I hereby certify that the specimen provided is my own and has not been substituted or adulterated. I further agree and grant permission for the testing of my specimen for drug metabolites and/or alcohol.

________________________________________________ Donor's Signature

___________________________________ Date

I hereby certify that I have collected the specimen provided by the aforementioned donor and that it was not substituted or adulterated to the best of my knowledge. The specimen temperature and color were acceptable.

_______________________________________________ Collector's Signature

___________________________________ Date

Initial Screen Results: (To be completed by screening personnel)

Drug Name Cocaine Marijuana

Opiates/Morphine Amphetamine

Methamphetamine Phencyclidine Benzodiazepine Barbiturates Methadone Tricyclic

Antidepressants Oxycodone

Propoxyphene Ecstasy

Alcohol Screen Adulteration Results

Device Code COC THC

OPI/MOR AMP mAMP PCP BZO BAR MTD TCA

OXY PPX MDMA

Negative

Confirm

ALC

Oxidant In Range Other____________

Specific Gravity In Range

Other____________

Level ->

PH In Range Other_____________

Not Tested

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