Test Results Record - Preferred Drug Testing - Minnesota

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TEST RESULTS RECORD
Company Information
Company Name _________________________________________________________________________
Address ________________________________________________________ Fax ___________________
City __________________________________ State/Province_________ Zip/Postal Code _____________
Name of Collector ____________________________________________ Phone _____________________
Donor Information
Last Name __________________________ First Name ______________ Employee I.D. _______________
Type of Identification Provided:
Driver’s License
Employee Photo I.D.
Other ___________________
Reason for test:
Pre-employment
Random
Reasonable cause
Post-accident
Other __________
Screen Results (Confirm results must be confirmed by laboratory)
Test Ref #: ________________ Date/Time Collected ____________________ Time Interpreted _________
Temperature: _________ _____ Normal (90-100°) _____ Other______________________
Note: Temperature must be read within four minutes of collection.
Drug Name
Symbol
Negative
Confirm
N/A
Cocaine
(COC)
______
______
______
Marijuana
(THC)
______
______
______
Opiates
(OPI)
______
______
______
Amphetamines
(AMP)
______
______
______
Phencyclidine
(PCP)
______
______
______
Benzodiazepine
(BZD)
______
______
______
Barbiturate
(BAR)
______
______
______
Methadone
(MTD)
______
______
______
Methamphetamine
(MET)
______
______
______
Tricyclic Antidepressants
(TCA)
______
______
______
Ecstasy
(MDMA)
______
______
______
Propoxyphene
(PPX)
______
______
______
Bupenorphrine
(BUP)
______
______
______
Adulterants
Normal
Abnormal
N/A
1. Creatinine
______
______
______
2. Nitrite
______
______
______
3. pH
______
______
______
4. Specific gravity
______
______
______
Alcohol
0% 0.04 0.08 0.20
1. Alcohol
___ ___ ___ ___
Certification
I hereby agree to submit to a urinalysis for the purpose of testing for drug metabolites. The specimen provided is my own
and has not been substituted or adulterated.
_______________________________________________________________
Donor signature
Date / Time
I hereby certify the specimen has been provided by the donor above.
_______________________________________________________________
Collector signature
Date / Time
I hereby certify that a secure sample was received for confirmation.
_______________________________________________________________
Laboratory signature
Date / Time received
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