STEP 3: COMPLETED BY COLLECTOR — INITIAL TEST RESULTS

TM

URINE INITIAL DRUG SCREEN RESULT FORM

Specimen ID Number

TO BE COMPLETED BY COLLECTOR

TO BE COMPLETED BY DONOR PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

COLLECTION SITE / COMPANY NAME NAME ADDRESS CITY PHONE

STATE FAX

SUITE POSTAL CODE

DONOR SSN, DRIVER'S LICENSE or EMPLOYEE I.D. NO.

ID VERIFIED BY: PHOTO ID q

EMPLOYER REP. q

DONOR NAME: Last:

First:

REASON FOR TEST:

Pre Employment q

COLLECTOR NAME (PRINT)

Random q

Reasonable Suspicion / Cause q

Post Accident q

Read specimen temperature within (4) minutes. Specimen within range: q Yes, 90? - 100?F (32? - 38?C)

Return to Duty q

Follow Up q

Other q ____________________________________________

Collector Phone No. (__________) _____________________________________ Collector Fax No. (__________) _____________________________________

q No, record specimen temperature here

STEP 2: COMPLETED BY DONOR

DONOR CONSENT: I certify that I provided my specimen to the collector, that the specimen container was sealed with a tamper proof seal in my presence and that the information provided on this form tests to the health care provider. In the case of screening for employment or

pre-employment, I also authorize release of the results of these tests to my employer or prospective employer and / or their authorized health care provider.

X

Signature of Donor

(Print) Donor's Name (First, MI, Last)

Date (Mo/Day/Yr)

Daytime Phone:

Evening Phone:

Date of Birth: Date (Mo/Day/Yr)

STEP 3: COMPLETED BY COLLECTOR -- INITIAL TEST RESULTS

ON-SITE SCREENING DEVICE preliminary results

Lot #: Exp. Date:

Screen performed by:

(If different than collector)

X

Date: Remarks:

SPECIMEN VALIDITY TEST RESULTS

(See color chart and package insert for interpretation)

Oxidant

Normal

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Abnormal [ ]

OX

Not Tested [ ]

Speci c Gravity

S.G.

pH

pH

Nitrite

Ni

GL

GL

Creatinine

CR

Normal

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Abnormal [ ]

Not Tested [ ]

Normal

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Abnormal [ ]

Not Tested [ ]

Normal

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Abnormal [ ]

Not Tested [ ]

Normal

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Abnormal [ ]

Not Tested [ ]

Normal

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Abnormal [ ]

Not Tested [ ]

DRUG NAME

Amphetamine (AMP) Barbiturates (BAR) Benzodiazepines (BZO) Buprenorphine (BUP) Cocaine (COC) Marijuana (THC) Methadone (MTD) Methamphetamine (mAMP) Ecstasy (MDMA) Opiate (OPI/MOP) Oxycodone (OXY) Phencyclidine (PCP) Propoxyphene (PPX) Tricyclic Antidepressants (TCA) Other

ALCOHOL SCREEN (If Performed) Results

PRESUMPTIVE

NEG

POSITIVE

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NOT TESTED

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STEP 4: COLLECTOR CERTIFICATION

COLLECTOR CERTIFICATION:

X

Signature of Collector

X

(Print) Collector's Name (First, MI, Last)

accordance with applicable requirements.

Time of Collection Date (Mo/Day/Yr)

? 2009. Inverness Medical. All rights reserved.

PN: 2380

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