Employee Drug Testing Report Form

EMPLOYEE DRUG TESTING REPORT FORM

Period Ending:

4104 Regulations for the Drug Testing of Contractor and Subcontractor Employees Working on

Large Public Works Projects requires that Contractors and Subcontractors who work on Large

Public Works Contracts funded all or in part with public funds submit Testing Report Forms to

the Owner no less than quarterly.

Project Number:

Project Name:

Contractor/Subcontractor Name:

Contractor/Subcontractor Address:

Number of employees who worked on the jobsite during the report period:

Number of employees subject to random testing during the report period:

Number of Negative Results

Number of Positive Results

Action taken on employee(s) in response to a failed or positive random test:

Authorized Representative of Contractor/Subcontractor:

(typed or printed)

Authorized Representative of Contractor/Subcontractor:

(signature)

Date: _______________

DRUG TESTING FORMS

01 35 00-1

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Parent category: Medical