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PDEA Drug Testing Form

This document contains forms from the Philippine Drug Enforcement Agency regarding mandatory drug testing. The first form is a certification where the client signs to confirm they have not tested positive for regulated drugs in the past six months. The second form is a consent form where the client provides personal information and consents to provide a urine sample for drug testing. The results will only be shared with the Drug-free Workplace Committee. By signing, the client confirms they understand and have answered all questions truthfully.

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Generis Sui
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4K views1 page

PDEA Drug Testing Form

This document contains forms from the Philippine Drug Enforcement Agency regarding mandatory drug testing. The first form is a certification where the client signs to confirm they have not tested positive for regulated drugs in the past six months. The second form is a consent form where the client provides personal information and consents to provide a urine sample for drug testing. The results will only be shared with the Drug-free Workplace Committee. By signing, the client confirms they understand and have answered all questions truthfully.

Uploaded by

Generis Sui
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

Office of the President


PHILIPPINE DRUG ENFORCEMENT AGENCY
REGIONAL OFFICE IX
36 Valor, Upper Calarian, Zamboanga City │ [email protected] │ (062) 983 0112

MANDATORY DRUG TEST


CERTIFICATION

I hereby certify to the best of my knowledge that I have not been found positive of any regulated drugs by any
Drug Test Laboratory for the past six (6) months. If I should be found making false statement to this regard, I
shall be held liable and shall be charged of perjury.

  
________________________________ _________________________________________________________ ___ ___________
Signature of Client (PRINT) Client’s Name (First,MI,Last) DATE

CONSENT FORM

Service/ Unit:________________________

Name:__________________________________________________________Date:___________Time:______
Last name First name Middle name
Address:_____________________________________________________________________________________
Birth date:______________ Age:______ Gender: __________________ Civil Status:________________
Place of Birth: ____________________________

Instructions: Answer the questions below by checking the appropriate boxes below. Afterwards, read the statements
below and sign the following signature.

 Have you taken medication or drugs in the past 30 days?  Yes  No


 Have you ingested any alcoholic beverage in the past 24 hours?  Yes  No
If you are taking medication of drugs list these items below: .

I hereby consent and agree to give a sample of my urine. The result of any tests performed will only be
provided to the Committee of the Drug-free workplace. My signature below acknowledges that I have read and
understood the foregoing statement and I have answered all the questions truthfully.

Date: ___/___/___ Signature: __________________________


(mm/dd/year)

FM-LSVexd-05
Rev 1; 12/17/2015
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