Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility (Page 5 of 6) in pdf

Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 5

UNEMPLOYMENT INSURANCE (UI) DRUG REPORT: PERFORMING THE TEST ANALYSIS

Name

Return to

Social Security Number

Hearing No.

Date Sent

Date Due

Phone Number

Fax Number

The purpose of this form is to resolve an UI eligibility claim for the above claimaint. The information

provided here will be shared with department personnel and the parties involved in the disputed claim.

1. What was the chain of custody, i.e., handling of the specimen from the time it was received to the time the test(s) was

completed? [Be specific as to the date, time and name(s).]

2. What type of specimen was tested?

3. What test(s) was conducted?

4. What procedure was used in conducting the test(s):

The Department of Transportation’s Workplace Drug Testing Program regulations, 49 CFR, part 40

Other (be specific):

What was the result of the test(s)—please indicate exact reading, preferably in ng/mL? (You may

attach laboratory test reports to answer this question. However, you must still sign this form.)

6. How long do the metabolites for the specific drug(s) identified remain in a person’s system [i.e., how long are the

specific drug(s) detectable after use]?

YOU MUST PROVIDE A COPY OF THE TESTING LABORATORY’S AND ANALYST’S

CERTIFICATION AND/OR CREDENTIALS.

CERTIFICATION is required by an individual who can attest to the accuracy of the information

provided.

I hereby certify, with full knowledge of the penalty of fine and/or imprisonment, as provided in Section

943.39 of the Wisconsin Statutes, that this report, together with any attached documents, truly and

correctly sets forth the above findings.

Signature

Printed Name

Title

Name of Laboratory or Clinic:

Address:

Phone Number (_________) __________________ Date:

3.31

April 2000

Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 5