Preliminary Drug Screen Result Form printable pdf download

Specimen ID # ____________________

Preliminary Drug Screen Result Form

Company Information

Company Name:___________________________________________________________________________________

Address:_________________________________________________________________________________________

Phone:______________________________________________ Fax:________________________________________

Donor Information

Donor Name:_______________________________________________ SSN or ID#:_____________________________

Test Information





Pre Employment

Random

Post Accident

Reasonable Suspicion

Reason for Test:

Periodic

Date of Collection:______________________________________

Time of Collection: ______ : ______ AM / PM



Specimen Type:

Oral Fluid

Urine

Temperature 90 – 100° F :

YES

Test Lot #: ___________________ Remarks:___________________________________________________________

Certification and Consent

I certify that the specimen provided is my own and has not been substituted or adulterated. I further agree and grant

permission for the testing of my specimen for the presence of drugs and/or alcohol. Also, I hereby give permission for the

release of the results of these test to my employer/prospective employer and/or their authorized healthcare professionals.

Donor Signature:_________________________________________________ Date:_____________________________

I certify that I collected the specimen provided by the aforementioned donor and that it was not substituted or adulterated

to the best of my knowledge.

Collector Signature:_______________________________________________ Date:_____________________________

Preliminary Test Results



 





Negative for all

Marijuana -THC

Cocaine - COC



 



Opiate-Morphine - OPI/MOR

Methamphetamine - mAMP









Amphetamine – AMP

Phencyclidine - PCP





Barbiturates – BAR

Benzodiazepine - BZO



Positive

Methadone – MTD

Ecstasy-MDMA





Tricyclic-TCA

Oxycodone - OXY

for the drugs marked:



Propoxyphene – PPX

Alcohol - ALC

Remarks:

(eg. specimen integrity checks)_______________________________________________________________

Confirmation





Specimen Sent to Lab for GC/MS Confirmation:

YES

Laboratory Specimen ID #:____________________

Preliminary Drug Screen Result Form

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