Drug Screen Result Form printable pdf download

EZ-Cup

Drug Screen Result Form

Company Information:

(information about the company doing the testing)

Company___________________________________________ Phone _____________

Address ______________________________________________ Fax _____________

City _____________________________ State ____________ Postal Code _________

Collector Name _____________________________________

Specimen Temperature: (90 – 100 F) In Range? (Circle response) YES NO

Donor Information:

(information about the person being tested)

Donor Name____________________________________________________________

Identification Type_________________________________ Expiration ___________

ID Number or SSN __________________________________

Certification Information:

(must be signed by Donor and Collector)

I hereby certify that I collected the specimen provided by the aforementioned Donor and that it

was not substituted or adulterated to the best of my knowledge. The specimen temperature

and color were acceptable.

Collection/Test Date

_________________________________________

__________________

Collector Signature

Date

I hereby certify that the specimen provided is my own and has not been substituted or adulterated.

I further agree and grant permission for the testing of my urine specimen for drug metabolites and,

or alcohol.

________________________________________

___________________

Donor Signature

Date

Negative Result

Non-Negative Result

Invalid Result

This screen shows a

This Screen shows a

This screen shows an OPI

This screen shows an

NEGATIVE result

NEGATIVE result, even a very

NON-NEGATIVE result

INVALID result

light line

indicates a

result.

NEGATIVE

Drug Name

Device Code

Negative

Confirm

Not Tested

Adulterant Pads (If Provided)

Cocaine

COC

Marijuana

THC

Normal

Abnormal

Opiates/Morphine

OPI

Oxidants (OX)

Amphetamines

AMP

Specific Gravity (SG)

Methamphetamines

mAMP

Nitrates (NIT)

Methylendioxymethamphetamine MDMA

Acidity (pH)

Phencyclidine

PCP

Benzodiazepine

BZO

Glutaraldehyde (GLUT)

Barbiturates

BAR

Creatinine (CRE)

Methadone

MTD

Oxycodone

OXY

Tri-Cyclic Antidepressants

TCA

9-2004

Drug Screen Result Form

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