Federal Drug Testing Custody And Control Form

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

800-877-7484

80283219

SPECIMEN ID NO.

LAB ACCESSION NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

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

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

AWSI / BAKER HUGHES INC

EMRO - Dr. Steve Kracht

7500 W 110th St. Ste 500

ANGELICA ROBERTS

PO Box 25903

17542 E 17TH ST STE 330

Overland Park, KS 66225

TUSTIN, CA 92780

Ph: 888-382-2281 Fax: 913-469-4029

PH: 713-466-2936 FAX: 713-466-2920

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

D. Specify Testing Authority:

HHS

NRC

DOT – Specify DOT Agency:

FMCSA

FAA

FRA

FTA

PHMSA

USCG

E. Reason for Test:

Pre-employment

Random

Reasonable Suspicion Cause

Post Accident

Return to Duty

Follow-up

Other (specify) ____________________________

F . Drug Tests to be Performed:

THC, COC, PCP , OPI, AMP

THC & COC Only

Other (specify) ________________________________________________

( ) 7643N DOT 5 Panel

G. Collection Site Name:

Collection Site Code:

Address:

Collector Phone No.:

City, State and Zip:

Collector Fax No.:

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

Collection:

Split

Single

None Provided, Enter Remark

Temperature between 90° and 100° F?

Yes

No, Enter Remark

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.

Quest Diagnostics Courier

X

FedEx

Other

Signature of Collector

AM

PM

Name of Delivery Service

(Print) Collector's Name (First, MI, Last)

Date (Mo./Day/Yr.)

Time of Collection

RECEIVED AT LAB OR IITF:

Primary Specimen

SPECIMEN BOTTLE(S) RELEASED TO:

Bottle Seal Intact

X

Yes

No

Signature of Accessioner

If No, Enter remarks

in Step 5A.

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

Date (Mo./Day/Yr.)

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

Marijuana Metabolite ( 9-THCA)

NEGATIVE

POSITIVE for:

6- Acetylmorphine

Methamphetamine

MDMA

DILUTE

Cocaine Metabolite (BZE)

Morphine

Amphetamine

MDA

PCP

Codeine

MDEA

REJECTED FOR TESTING

ADULTERATED

SUBSTITUTED

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.

X

Signature of Certifying Scientist

(Print) Certifying 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 and reported in accordance with applicable Federal requirements.

Laboratory Name

X

___________________________________________

Laboratory Address

Signature of Certifying Scientist

(Print) Certifying Scientist's Name (First, MI, Last)

Date (Mo./Day/Yr.)