Affidavit Of Correction
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1AFFIDAVIT OF CORRECTION
According to 49 CFR Part 40, as amended, the collector of the drug test referenced below must take all practicable
action to correct errors on the Federal Drug Testing Custody and Control Form so that the test is not cancelled.
Transit System Name: __________________________________________ Date of Test:__________________________
Test Category: _______________________________________ Specimen ID#:__________________________________
Donor Name: ________________________________________ Collector Name:________________________________
Date Collector Was Notified of Error: ___________________________________________________________________
This affidavit addresses the following errors that were not performed in accordance with 49 CFR Part 40, as amended:
Step 1 Requirements (§40.63)
(check all that apply)
___ A. Missing/Incorrect Employer Name, Address
___ B. Missing/Incorrect MRO Name, Address, Phone and Fax No.
___ C. Missing Donor SSN or Employee I.D. No.
___ D. Missing/Incorrect Testing Authority
___ E. Missing/Incorrect Reason for Test
___ F. Missing/Incorrect Drug Tests to be Performed
___ G. Missing/Incorrect Collection Site Name, Address, Phone and Fax No.
Step 2 Requirements (§40.65-70)
(check all that apply)
___ Collector failed to indicate if the specimen was within the acceptable temperature range
___ Collector failed to mark ‘Split’
___ Collector arbitrarily marked ‘Observed’
___ Collector failed to mark ‘Observed’
___ Missing explanation within ‘Remarks’ section. (i.e. any unusual circumstances that occur during collection)
Step 3 Requirements (§40.71)
(check all that apply)
___ Bottle seals were filled out while still affixed to the CCF
Step 4 Requirements (§40.73)
(check all that apply)
___ Missing collector’s signature
___ Missing collector’s printed name (First, MI, Last)
___ Missing/Incorrect Date of Collection
___ Missing/Incorrect Time of Collection
___ Missing Courier Name
Step 5 Requirements (§40.73)
(check all that apply)
___ Missing donor’s signature
___ Missing donor’s printed name (First, MI, Last)
___ Missing/Incorrect Date of Collection
___ Missing donor’s Daytime and/or Evening Phone No.
___ Missing/Incorrect donor’s Date of Birth
Collector Remarks:
1. Description of error:_______________________________________________________________________________
2. Description of corrective action:______________________________________________________________________
3. Measures taken to ensure the same error(s) do not reoccur:_________________________________________________
__________________________________________________________________________________________________
By signing below, in accordance with 49 CFR Part 40.209, I certify that the aforementioned errors occurred on the
referenced drug test and that appropriate measures have been taken to ensure the same errors will not reoccur.
________________________________________________
_________________________________________
Collector Signature / Title
Date
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