Record Results Form

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? q Yes q 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? q Yes q No Notes:__________________________________

Code

Substance

Negative

Preliminary Positive

Not Tested

mAMP

Methamphetamine

COC

Cocaine

THC

Marijuana

AMP

Amphetamine

OPI

Opiates

OXY

Oxycodone

MTD

Methadone

BZO

Benzodiazepine

BAR

Barbiturates

MDMA

Methylenedioxymethamphetamine

PCP

Phencyclidene

BUP

Buprenorphine

TCA

Tricyclic Antidepressants

ALC

Alcohol

Level:

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: _____________________