2010 Report Form Of Valid Positive Result On Drug Test
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2rePort of valid PoSitive reSUlt on
drUG teSt Under trC 644.252
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by signing below, i, the Medical review officer (Mro) certify the following:
1. i am the Mro for the drug testing program or consortium of the motor carrier listed above.
2. i am a licensed physician with knowledge of substance abuse disorders.
3. this individual is subject to a report of a valid positive result of a drug test under trC §644.252 because:
the individual tested positive for the following substance(s);
Marijuana metabolites
amphetamines
Cocaine metabolites
Phencyclidine (PCP)
opiate metabolites (teSt reSUlt for oPiateS onlY - gC/MS confirmation does not confirm the presence of
6-monoacetylmorphine) i determined that there is clinical evidence, in addition to the urine test,
of unauthorized use of an opium, opiate, or opium derivative or the level is 15,000 or above;
or
the individual refused to submit to testing by:
Submitting an adulterated, diluted, or substituted specimen.
refusing to submit a specimen
refusing to cooperate with the specimen collection process or submit to follow-up testing or evaluation.
4. i followed the drug testing procedures required by 49 Cfr Parts 40 and 382 (or other parts applicable to CDl holders)
applicable to the Mro. i reviewed the chain of custody of the specimen submitted by the individual tested to ensure that it is
complete and sufficient on its face; examined any alternative medical explanations for the positive drug test result; and gave
the individual tested an opportunity to discuss the test result prior to making a final decision to verify the positive test result:
i talked directly with the individual tested before verifying the test as positive; or
after making all reasonable efforts to contact the individual tested, including contacting a designated management
official of the motor carrier, i was unable to communicate directly with the individual within 10 days of the date i
received the test result from the laboratory; or
the individual tested was instructed by the designated management official of the motor carrier to contact me and the
individual then failed to contact me within 72 hours; or
the individual tested expressly declined an opportunity to discuss the test result.
i further certify that i have reviewed my records and that the information contained in this certificate is true and correct
to the best of my knowledge.
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by signing below, i, the authorized representative of the Motor Carrier listed above, certify the following:
1. the Motor Carrier listed above:
has an in-house drug and alcohol testing program that meets the federal requirements of 49 Cfr Parts 40 and
382 (or other parts applicable to CDl holders); or
is a member of a consortium, as defined in 49 Cfr 382.107, that provides drug and alcohol testing that meets
the federal requirements of 49 Cfr Parts 40 and 382 (or other parts applicable to CDl holders).
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: ______________________________________________________________________
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onSortiUM
2. the individual tested is subject to drug testing by the Motor Carrier, and was tested for the following reason:
random
reasonable Suspicion
Post-accident
return to Duty
follow-up
Pre-employment
other ________________________;
and
tested positive for a prohibited drug under 49 Cfr Parts 40 and 382 (or other parts applicable to CDl holders) (note: a copy of
the federal drug testing custody and control form or the Mro’s report of positive controlled substance result must be attached); or
refused to submit to a controlled substance test (note: Mro certification is not required)
i further certify that i have reviewed the motor carrier’s records and that the information contained in this certificate is
true and correct to the best of my knowledge.
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, 6200 g
, MSC #0521, a
, tx 78752-4019,
fax legible
512/424-5310.
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MCS-20 9/10)
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