The Drug Screen form is a critical document used in the process of drug testing, particularly in workplace settings. It facilitates the collection, handling, and analysis of biological specimens to ensure compliance with federal regulations. Understanding its components and requirements is essential for employers and employees alike.
To begin the process of drug screening, fill out the form by clicking the button below.
The Drug Screen form, officially known as the Federal Drug Testing Custody and Control Form, plays a crucial role in the drug testing process for employers and employees alike. This form is essential for documenting the collection, handling, and testing of urine specimens to ensure compliance with federal regulations. It includes key sections that must be filled out by both the collector and the employer representative, such as the employer's name, the Medical Review Officer's (MRO) contact information, and the donor's identification number. The form specifies the testing authority, whether it be the Department of Transportation (DOT) or another agency, and outlines the reasons for testing, which can range from pre-employment to post-accident scenarios. Additionally, it lists the specific drug tests to be performed, including common substances like THC and cocaine. The collection site information, along with the collector's details, is also documented to maintain transparency. Importantly, the form incorporates steps for maintaining the chain of custody, ensuring that the specimen is collected, sealed, and transported according to established protocols. This meticulous process helps uphold the integrity of the testing results, whether they are negative or positive, and provides a basis for any further action that may be required.
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When filling out and using the Drug Screen form, it is essential to pay attention to several key aspects to ensure accuracy and compliance.
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
800-877-7484
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
LAB ACCESSION NO.
Quest, Quest Diagnostics, the associated logo and all associated Quest Diagnostics marks are the trademarks of Quest Diagnostics Incorporated. © Quest Diagnostics Incorporated. All rights reserved. QD20315-FED. Revised 10/10. SC2K - 111192.
A. Employer Name, Address, I.D. No.
B. MRO Name, Address, Phone and Fax No.
C. Donor SSN or Employee I.D. No. _______________________________________________________________
D. SpecifyTesting Authority: HHS
NRC
DOT – Specify DOT Agency: FMCSA
FAA
FRA FTA PHMSA USCG
E. Reason forTest: Pre-employment
Random
Reasonable Suspicion Cause Post Accident
Return to Duty
Follow-up Other (specify) ____________________________
F. DrugTests to be Performed:
THC, COC, PCP, OPI, AMP
THC & COC Only
Other (specify) ________________________________________________
G. Collection Site Name:
Collection Site Code:
Address:
Collector Phone No.:
City, State and Zip:
Collector Fax No.:
STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.
Temperature between 90° and 100° F? Yes No, Enter Remark
Collection: Split Single None Provided, Enter Remark
Observed, (Enter Remark)
REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was
SPECIMEN BOTTLE(S) RELEASED TO:
collected, labeled, sealed, and released to the Delivery Service noted in accordance with applicable Federal requirements.
Quest Diagnostics Courier
X
FedEx
Signature of Collector
Other
AM
PM
(Print) Collector's Name (First, MI, Last)
Date (Mo./Day/Yr.)
Time of Collection
Name of Delivery Service
RECEIVED AT LAB OR IITF:
Primary Specimen
Bottle Seal Intact
Yes No
Signature of Accessioner
If No, Enter remarks
in Step 5A.
(Print) Accessioner’s Name (First, MI, Last)
STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY
NEGATIVE
POSITIVE for:
Marijuana Metabolite ( 9-THCA)
6- Acetylmorphine
Methamphetamine
MDMA
DILUTE
Cocaine Metabolite (BZE)
Morphine
Amphetamine
MDA
PCP
Codeine
MDEA
REJECTED FOR TESTING
ADULTERATED
SUBSTITUTED
INVALID RESULT
REMARKS:
Test Facility (if different from above):
I certify that the specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable Federal requirements.
Signature of Certifying Scientist
(Print) Certifying Scientist's Name (First, MI, Last)
STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY
RECONFIRMED FAILED TO RECONFIRM - REASON ____________________________________________
___________________________________________
I certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody
procedures, analyzed and reported in accordance with applicable Federal requirements.
Laboratory Name
Laboratory Address
OMB No. 0930-0158
PRESS HARD - YOU ARE MAKING MULTIPLE COPIES