Collection Site Checklist

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COLLECTION SITE CHECKLIST
Name of Collection Site: _____________________________________________
Date of Review: _________________________
Name of Collector: _____________________________________ Name of Reviewer: ___________________________________
49 CFR Part 40. You may view this form on the
UNEVENTFUL BREATH ALCOHOL TEST
ODAPC website ( )
(result less than 0.02) - Did the Breath Alcohol
 Were all necessary equipment, personnel, and materials for
Technician (BAT)...
breath testing provided at the location where testing
 Require employee to provide positive photo identification
occurred? (40.221(d))
(Part 40.241(c)).
 Did the breath alcohol testing location afford visual and
 Perform the Alcohol test before the drug test, if applicable
aural privacy to prevent unauthorized persons from seeing
 Explain testing procedures on back of Alcohol Testing
or hearing test results? (40.221(c))
Form (ATF) (40.241(e))
 Did the BAT remain with the employee for the entire
 Complete Step 1 of ATF (40.241(f))
duration of the alcohol testing procedure? (40.223(e)(3))
− Employee Name, ID Number
 Does the BAT have a copy of the quality assurance plan
− Employer Name and Contact information
(QAP) for the EBT? (40.233(c))
− DER Name and Telephone Number
 Ask to see the external calibration checks for the EBT
− Reason for Test
(40.233(c))
 Have the employee complete Step 2 of the ATF (40.241(g))
 Have the BATs completed the required training and
 Open individually sealed mouthpiece and attach to EBT
acquired the proper credentials? (40.213(g))
 Ask to see the credentials of the BAT
(40.243(b))
 Instruct employee to blow forcefully until EBT indicates
 Does the BAT have a current copy of 49 CFR Part 40?
that an adequate amount of breath has been obtained
(40.213)
(40.243(c))
 Show employee the result displayed on EBT (40.243(d))
UNEVENTFUL URINE COLLECTION - Did
 If EBT prints result on paper strip: Did the BAT affix the
the Collector…
strip to the ATF using tamper evident tape (40.243(f))
 Require employee to provide positive identification
 If EBT does not print results on paper strip: Did the BAT
(Part 40.61(c)).
complete the following information on Step 3 of the ATF
 Direct the employee to remove outer clothing (jacket,
(40.243(g)):
hat) and to leave these garments and other personal
Identification of the machine
items (briefcase, purse, etc.) in a mutually agreeable
Time
location (Part 40.61(f)).
Sequential Test Number
- Advises employee that failure to comply
Test Outcome
constitutes a refusal to test.
 Complete Step 3 of the ATF by dating and signing the
- Allows employee to keep wallet (40.61(f)(2)).
certification (40.247(a))
 Direct employee to empty pockets and display items
 Distribute the ATF copies to appropriate individuals
in them (Part 40.61(f)(4)).
(40.247(a)):
- If no potential adulterants are found, allow
− Copy 1 to Employer
employee to return items to pockets.
− Copy 2 to Employee
 Complete Step 1 of CCF (Part 40.63(a)).
− Retain Copy 3
- Ensures that the name and address of the drug
After the Breath Alcohol Test is completed, review the
testing laboratory appears at the top of the CCF.
following items:
- Ensures that the Specimen ID at the top of the
 Was consent - giving the collection site or its personnel
CCF matches the Specimen ID on labels/seals.
indemnification - required for testing? (40.355(a))
- Checks the Reason for Test box (Pre-
− Collection sites cannot require an employee to sign a
Employment, Random, Post-Accident, etc.).
consent, release, waiver of liability, or indemnification
- Checks the DOT and the FTA box (Testing Authority)
agreement with respect to any part of the alcohol or
- Checks the Drug Tests to Be Performed box
drug testing process covered by 49 CFR Part 40. No
(THC, COC, PCP, OPI, AMP for DOT).
one may do so on behalf of a service agent
 Instruct employee to wash/dry hands and not to
 Is the EBT on the National Highway Traffic Safety
wash hands again until delivering specimen to
Administration (NHTSA) conforming products list?
collector (Part 40.63(b)).
 Was the correct ATF used? (40.225(a))
 Ensure collection container is selected and
− The DOT ATF must be used for every DOT alcohol
unwrapped in presence of employee (Part 40.63(c)).
test. The ATF must be a three-part carbonless
manifold form. The ATF is found in Appendix G of
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