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Drug Screen Result Form Final

This document is a drug screen result form containing donor information such as name, SSN, DOB, and contact details. It lists 11 common drugs that may be tested for using urine samples, including cocaine, marijuana, opiates, methamphetamine, and alcohol. The donor signs to consent to the drug screening and certify the sample. Screening personnel verify the donor's identity and sample integrity and sign the form as well.

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zahid- tech
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4K views1 page

Drug Screen Result Form Final

This document is a drug screen result form containing donor information such as name, SSN, DOB, and contact details. It lists 11 common drugs that may be tested for using urine samples, including cocaine, marijuana, opiates, methamphetamine, and alcohol. The donor signs to consent to the drug screening and certify the sample. Screening personnel verify the donor's identity and sample integrity and sign the form as well.

Uploaded by

zahid- tech
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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128 Court St 2nd Fl

White Plains NY 10601


914-358-9160 Drug Screen Result Form
[email protected]

DONOR INFORMATION COMPANY INFORMATION


Donor Name: _____________________________________ Company/Referring Agency: _____________________
SSN: ____________________ DOB:____________________ ___________________________________________________
Phone: _________________________ Address: _________________________________________
Email: ____________________________________________ City:________________ State: __________ Zip:________
Reason for Test: Pre-employment Random Phone: _________________________
Post Accident Other________________________ Email: ____________________________________________

TO BE COMPLETED BY DONOR:
I 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. I voluntarily consent to this testing.

_________________________________________________ ____________________________________________ ____________________________________


Print Donor Name Donor’s Signature Date / Time

TO BE COMPLETED BY SCREENING PERSONNEL


Drug Name Device Code Cut-Off-Level Negative Positive Not Tested
Cocaine COC 300ng/ml
Marijuana THC 50ng/ml
Opiates OPI 2000ng/ml
Meth-Amphetamine METH 1000ng/ml
Amphetamine AMP 1000ng/ml
Methadone MTD 300ng/ml
Burprenorphine BUP 10ng/ml
Benzodiazepines BZO 300ng/ml
MDMA MDMA 500ng/ml
Oxycodone OXY 100ng/ml
Alcohol ETG 500ng/ml

Specimen Temperature (90-100 F.) Yes No


I certify that l 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 I have verified the donor identity by review of the donor’s picture lD or by employer or test
request or verification.

_________________________________________________ ____________________________________________ _____________________________________


Print Collector Name Collector’s Signature Date / Time

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