Offical Drug Screen Report Forms - Rapid Detect
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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