This document is a consent form for drug testing from the Manila Health Department Public Health Laboratory. It requests information from test subjects such as their name, address, date of birth, purpose of the drug test, medications taken, and consent to provide urine, blood, saliva, or other samples. It outlines the sample collection and chain of custody procedures, and certifications that the sample belongs to the subject and was not altered. The subject also consents to let their sample be sent for confirmatory testing if initially found positive.
This document is a consent form for drug testing from the Manila Health Department Public Health Laboratory. It requests information from test subjects such as their name, address, date of birth, purpose of the drug test, medications taken, and consent to provide urine, blood, saliva, or other samples. It outlines the sample collection and chain of custody procedures, and certifications that the sample belongs to the subject and was not altered. The subject also consents to let their sample be sent for confirmatory testing if initially found positive.
This document is a consent form for drug testing from the Manila Health Department Public Health Laboratory. It requests information from test subjects such as their name, address, date of birth, purpose of the drug test, medications taken, and consent to provide urine, blood, saliva, or other samples. It outlines the sample collection and chain of custody procedures, and certifications that the sample belongs to the subject and was not altered. The subject also consents to let their sample be sent for confirmatory testing if initially found positive.
This document is a consent form for drug testing from the Manila Health Department Public Health Laboratory. It requests information from test subjects such as their name, address, date of birth, purpose of the drug test, medications taken, and consent to provide urine, blood, saliva, or other samples. It outlines the sample collection and chain of custody procedures, and certifications that the sample belongs to the subject and was not altered. The subject also consents to let their sample be sent for confirmatory testing if initially found positive.
●Purpose of Drugtest EMPLOYMENT PRIVATE GOVERNMENT LICENSE DRIVER'S FIREARM'S STUDENT SECONDARY SCHOOL TERTIARY SCHOOL Candidate for Public Office wheter Appointee or Elected Person apprehended or arrested for violating the provisions of this act Persons charge before the Prosecutor’s Office with a criminal offense having an imposable penalty of imprisonment of not less than six (6) years and (1) day Others (please specify) Instructions: Answer the questions below by checking the appropriate spaces below your answer. Afterwards, read the statements below signing the two for your signature. ●Have you taken any 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 sample of my:
URINE BLOOD SALIVA HAIR SWEAT The result of any tests performed shall be provided to the requesting office or agency. My signature below acknowledges that I have read and understood the foregoing statement and i have answered all the questions truthfully. ●Date: ●Signature: I hereby consent and agree that my● specimen, if found positive be sent to duly accredited/licensed Confirmatory Laboratory for confirmatory test. I hereby acknowledge that the ● sample is my own and that the samples were sealed in my presence. These samples are to be tested for dangerous drugs.
●Date: ●Signature:
CERTIFICATION I hereby certify to the best of my knowledge that I have not been found positive of any Regulated Drugs by any Drug Testing Laboratory for the past six (6) months. And that should I be found making false statements to this regard, I shall be held liable and shall be charged of perjury. And that all appurtenances in case I shall be found negative by this Drug Testing Laboratory shall be revoked as a consequence of such false statements.
●NAME
●SIGNATURE ●COMPLETE ADDRESS ●DATE
CITY OF MANILA MANILA HEALTH DEPARTMENT PUBLIC HEALTH LABORATORY TAPUSIN ANG PROSESO NG DRUG TEST (PAG-IHI AT BIOMETRICS) PETSA NG PAGPUNTA: _______________________ Ako po si ___________________________________________________ (pangalan ng aplikante) pagkatapos ng pagsubmit ng aking IHI para sa pagsusuri (DRUG TEST) ako ay tutungo sa BIOMETRICS area para magpalitrato at finger scan. Naiintindihan ko na nakapagsubmit na ako ng ihi at nasuri na, ngunit hindi ako nakatungo sa pagbibiometrics (para magpakuha ng litrato at finger print sa araw din na iyon (same day ihi at biometrics), magiging invalid na ang nasabing pagsusuri at kailangan ko nang ulitin ang proseso ng pagpapadrugtest kasama ang kaukulang bayad na 250 pesos para sa DRUG TEST.
lagda ng DONOR / APLIKANTE
SAMPLE NG STOOL / DUMI I certify that the stool sample I submitted is mine and not altered. (Pinapatunayan ko na ang sample ng akong isinumite ay akin at hindi alter.
lagda ng DONOR / APLIKANTE
MANILA HEALTH DEPARTMENT – PUBLIC HEALTH LABORATORY 1559 Alvarez Street Barangay 334 Santa Cruz Manila Tel No. 5310-1329 CUSTODY AND CONTROL FORM (Form DT – 002.B – COPY FOR THE COLLECTION SITE) SPECIMEN ID NO.: LAB ACCESSION NO.:
STEP 1 COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
Client’s/Donor’s/Subject’s Code ●AGE: ●SEX: Male Female ●ADDRESS: Employer's Name and Address TYPE OF SPECIMEN ●REASON FOR TEST URINE Pre-employment Random Reasonable Suspicion / Cause BLOOD Return-to-Duty Mandatory Post Accident OTHERS (SPECIFY) Follow-up Others (specify) DRUG TEST TO BE PERFORMED : THC, COC, PCP, OPI, AMP THC & MET ONLY OTHERS (SPECIFY):__________________________ STEP 2 COMPLETED BY COLLECTOR Read specimen temp. within 4 mins. Specimen Collection: Observed Unobserved Other Observation (Enter Remark) o o Is temperature between 32 C & 38 C? Specimen Sampling: Single Split Yes No Specimen Volume ______ml Physical Appearance: Color ______ REMARKS: STEP 3 Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initial seal(s). Donor completes STEP 5. STEP 4 CHAIN OF CUSTODY – INITIATED BY COLLECTOR AND COMPLETED BY LABORATORY. I certify that the specimen given to me by the identified in the certification section on Step 5 of this form was collected, sealed and released to the Delivery Service noted in accordance with applicable DOH requirements. SPECIMEN BOTTLE(S) RELEASED TO: X____________________________ _____________ AM/PM Signature of Collector Time of Collection _____________________________ _____________________ _____ ______________________________________________ (PRINT) Collector’s Name (First,M.I.,Last) Date (mm/dd/year) Name of Delivery Service Transferring Specimen to Lab. RECEIVED AT LAB: STATUS OF THE SPECIMEN: SPECIMEN BOTTLE(S) RELEASED TO: X____________________________ _____________ AM/PM a) Seal Intact Yes No ______________________ Signature of Accessioner Time of Collection b) Transport Service _____ Signature of Receiving Person ______________________________ _____________ c) Description __________ _______________ ____________ (PRINT) Accessioner’s Name(First,MI,Last) Date(mm/dd/year) Printed Name (First,MI,Last) Date(mm/dd/year) STEP 5 COMPLETED BY THE DONOR I certify that I provided my urine specimen to the collector, that I have not adulterated it in any manner, each specimen bottle used was sealed with a tamper-evident seal in my presence and that the information on this form on the bottle is correct.
●SIGNATURE OF DONOR ●(PRINT) DONOR’S NAME (FIRST, MI, LAST) ● Date(mm/dd/year)
●Contact No. ●Date of Birth (mm/dd/year)
Additional information may be asked from you by the laboratory particularly on drug and medications. STEP 6 COMPLETED BY HEAD OF SCREENING LABORATORY In accordance with applicable Department of Health requirements, my determination/verification is: NEGATIVE POSITIVE TEST CANCELLED REFUSAL TO TEST BECAUSE: DILUTED SUBSTITUTED REMARKS _________________________________________________ ADULTERATED OTHERS(specify)
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year) STEP 7 COMPLETED BY CONFIRMATORY LABORATORY In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is: CONFIRMED FOR: CHALLENGE FAILED TO CONFIRM - REASON ________________________ THC MET OTHERS (SPECIFY)________________
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year) STEP 8 COMPLETED BY THE NATIONAL REFERENCE LABORATORY (NRL) In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is: RECONFIRMED FOR: FAILED TO RECONFIRM - REASON ________________________ THC MET OTHERS (specify)_________________
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year)
PAUNAWA HUWAG PO SUSULATAN
PAUNAWA: SULATAN LAMANG ANG MAY CHECK PAUNAWA: SULATAN LAMANG ANG MAY CHECK DATE: ____________ CONTROL NUMBER: ____ DATE: ____________ CONTROL NUMBER: ____ NAME: __________________________________ NAME: __________________________________ AGE: ____ O.R. / REFERENCE NUMBER AGE: ____ O.R. / REFERENCE NUMBER SEX: ____ SEX: ____ PURPOSE (Ano ang paggagamitan) Lagyan ng check ang BOX PURPOSE (Ano ang paggagamitan) Lagyan ng check ang BOX HEALTH CERT CGEC PHL / OPD OTHERS________________ HEALTH CERT CGEC PHL / OPD OTHERS________________
EXAMINATION: EXAMINATION: MANILA HEALTH DEPARTMENT – PUBLIC HEALTH LABORATORY 1559 Alvarez Street Barangay 334 Santa Cruz Manila Tel No. 5310-1329 CUSTODY AND CONTROL FORM (Form DT – 002.C – COPY FOR THE COLLECTION SITE) SPECIMEN ID NO.: LAB ACCESSION NO.: STEP 1 COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE Client’s/Donor’s/Subject’s Code ●AGE: ●SEX: Male Female ●ADDRESS: Employer's Name and Address TYPE OF SPECIMEN ●REASON FOR TEST URINE Pre-employment Random Reasonable Suspicion / Cause BLOOD Return-to-Duty Mandatory Post Accident OTHERS (SPECIFY) Follow-up Others (specify) DRUG TEST TO BE PERFORMED : THC, COC, PCP, OPI, AMP THC & MET ONLY OTHERS (SPECIFY):__________________________ STEP 2 COMPLETED BY COLLECTOR Read specimen temp. within 4 mins. Specimen Collection: Observed Unobserved Other Observation (Enter Remark) Is temperature between 32oC & 38oC? Specimen Sampling: Single Split Yes No Specimen Volume ______ml Physical Appearance: Color ______ REMARKS: STEP 3 Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initial seal(s). Donor completes STEP 5. STEP 4 CHAIN OF CUSTODY – INITIATED BY COLLECTOR AND COMPLETED BY LABORATORY. I certify that the specimen given to me by the identified in the certification section on Step 5 of this form was collected, sealed and released to the Delivery Service noted in accordance with applicable DOH requirements. SPECIMEN BOTTLE(S) RELEASED TO: X____________________________ _______________ AM/PM Signature of Collector Time of Collection _____ _____________________________ _____________________ (PRINT) Collector’s Name (First,M.I.,Last) Date (mm/dd/year) Name of Delivery Service Transferring Specimen to Lab. RECEIVED AT LAB: STATUS OF THE SPECIMEN: SPECIMEN BOTTLE(S) RELEASED TO:
X____________________________ _____________ AM/PM a) Seal Intact Yes No ______________________
Signature of Accessioner Time of Collection b) Transport Service _____ Signature of Receiving Person ______________________________ _____________ c) Description __________ ______________________ ____________ (PRINT) Accessioner’s Name(First,MI,Last) Date(mm/dd/year) Printed Name (First,MI,Last) Date(mm/dd/year) STEP 5 COMPLETED BY THE DONOR I certify that I provided my urine specimen to the collector, that I have not adulterated it in any manner, each specimen bottle used was sealed with a tamper-evident seal in my presence and that the information on this form on the bottle is correct.
●SIGNATURE OF DONOR ●(PRINT) DONOR’S NAME (FIRST, MI, LAST) ● Date(mm/dd/year)
●Contact No. ●Date of Birth (mm/dd/year)
STEP 6 COMPLETED BY HEAD OF SCREENING LABORATORY
In accordance with applicable Department of Health requirements, my determination/verification is: NEGATIVE POSITIVE TEST CANCELLED REFUSAL TO TEST BECAUSE: DILUTED SUBSTITUTED REMARKS_________________________________________________ ADULTERATED OTHERS(specify)_________ X_________________________________________ ______________________________________________________ _________________ (PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year) STEP 7 COMPLETED BY CONFIRMATORY LABORATORY In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is: CONFIRMED FOR: CHALLENGE FAILED TO CONFIRM - REASON ________________________ THC MET OTHERS (SPECIFY)________________ X_________________________________________ ______________________________________________________ _________________ (PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year) STEP 8 COMPLETED BY THE NATIONAL REFERENCE LABORATORY (NRL) In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is: RECONFIRMED FOR: FAILED TO RECONFIRM - REASON ________________________ THC MET OTHERS (specify)_________________ X_________________________________________ ______________________________________________________ _________________ (PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year)
