NCADD-NJ WFNJ-SAI/SARD
NCADD-NJ WFNJ-SAI/BHI
UDS RESULTS REPORTING FORM
Client Name:______________________________________________________
Client DOB:___________ WFNJ#______________
Provider Agency Name: _____________________________________________
Urine Sample was analyzed by: (must choose one)
Outside Lab_______ In House Analysis_________ Use of Instant Kit_________
DATE OF OBSERVED UDS: ___________________
(check one for each substance)
Alcohol __________ __________ __________
(positive) (negative) (not tested)
Amphetamines __________ __________ __________
(positive) (negative) (not tested)
Barbiturates __________ __________ __________
(positive) (negative) (not tested)
Benzodiazepines __________ __________ __________
(positive) (negative) (not tested)
Cocaine __________ __________ __________
(positive) (negative) (not tested)
Opiates __________ __________ __________
(positive) (negative) (not tested)
Methadone __________ __________ __________
(positive) (negative) (not tested)
THC __________ __________ __________
(positive) (negative) (not tested)
Other __________ __________ __________
(positive) (negative) (not tested)
_____________________
(identify substance)
................
................
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