Federal Drug Testing Custody And Control Form printable pdf download

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

0000001

SPECIMEN ID NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

ACCESSION NO.

A. Employer Name, Address, I.D. No.

B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN or Employee I.D. No.

D. Specify Testing Authority: c HHS

c NRC

c DOT – Specify DOT Agency:

c FMCSA

c FAA

c FRA

c FTA

c PHMSA

c USCG

E. Reason for Test: c Pre-employment c Random c Reasonable Suspicion/Cause c Post Accident c Return to Duty c Follow-up c Other (specify)

F. Drug Tests to be Performed:

c THC, COC, PCP, OPI, AMP

c THC & COC Only

c Other (specify)

G. Collection Site Address:

Collector Phone No.

Collector Fax No.

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

Temperature between 90º and 100º F?

c Yes

c No, Enter Remark

Collection:

c Split

c Single

c None Provided, Enter Remark

c Observed, Enter Remark

REMARKS

STEP 3: Collector afﬁxes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)

STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY

I certify that the specimen given to me by the donor identiﬁed in the certiﬁcation section on Copy 2 of this form was

SPECIMEN BOTTLE(S) RELEASED TO:

collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.

Signature of Collector

(PRINT) Collector’s Name (First, MI, Last)

Date (Mo/Day/Yr)

Time of Collection

Name of Delivery Service

RECEIVED AT LAB OR

IITF

Primary Specimen

SPECIMEN BOTTLE(S) RELEASED TO:

Bottle Seal Intact

c YES

c NO

Signature of Accessioner

If NO, Enter remark

in Step 5 A.

(PRINT) Accessioner’s Name (First, MI, Last)

Date (Mo/Day/Yr)

STEP 5 A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY

c NEGATIVE

c POSITIVE for: c Marijuana Metabolite (∆9-THCA)

c 6-Acetylmorphine

c Methamphetamine

c MDMA

c DILUTE

c Cocaine Metabolite (BZE)

c Morphine

c Amphetamine

c MDA

c PCP

c Codeine

c MDEA

c REJECTED FOR TESTING

c ADULTERATED

c SUBSTITUTED

c INVALID RESULT

REMARKS:

Test Facility (if different from above) :

I certify that the specimen identiﬁed on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable Federal requirements.

Signature of Certifying Technician/Scientist

(PRINT) Certifying Technician/Scientist’s Name (First, MI, Last)

Date (Mo/Day/Yr)

STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY

RECONFIRMED

FAILED TO RECONFIRM - REASON

I certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed,

Laboratory Name

and reported in accordance with applicable Federal requirements.

Laboratory Address

Signature of Certifying Scientist

(PRINT) Certifying Scientist’s Name (First, MI, Last)

Date (Mo./Day/Yr.)

0000001

Date (Mo/Day/Yr)

SPECIMEN BOTTLE

0000001

SEAL

SPECIMEN ID NO.

0000001

Date (Mo/Day/Yr)

SPECIMEN BOTTLE

0000001

(SPLIT)

SEAL

SPECIMEN ID NO.

COPY 1 - TEST FACILITY COPY

Federal Drug Testing Custody And Control Form

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