Drug Screen PDF Template

The Drug Screen form is a document used to ensure the proper collection and testing of biological specimens for drug use. It outlines the responsibilities of collectors, employers, and laboratories in maintaining the integrity of the testing process. For accurate results, it is essential to complete this form thoroughly; begin by filling it out by clicking the button below.

Article Guide

The Drug Screen form is an essential document used in the process of drug testing, particularly in compliance with federal regulations. This form serves multiple purposes, beginning with the collection of vital information from both the employer and the donor. Key sections include the employer's details, such as name, address, and identification number, alongside the Medical Review Officer's (MRO) contact information. The form also requires the donor's Social Security Number or employee ID, ensuring accurate identification. A significant part of the form is dedicated to specifying the testing authority, which could include agencies like HHS, NRC, or DOT, along with the reason for the test—whether it’s pre-employment, random, or due to reasonable suspicion. Additionally, the form outlines the specific drug tests to be performed, covering substances like THC, cocaine, and amphetamines, among others. The collection site details are crucial, providing information about where the specimen is obtained, including the collector's contact information. Following the collection, the chain of custody is meticulously documented to maintain the integrity of the specimen. Each step, from temperature checks to the sealing of specimen bottles, is recorded to ensure compliance with federal requirements. The form ultimately concludes with a report on the test results, confirming whether the specimen was negative, positive, or invalid. This comprehensive approach not only protects the rights of all parties involved but also upholds the standards of workplace safety and accountability.

Drug Screen Preview

C. Donor SSN or Employee I.D. No. _______________________________________________________________

D. Specify Testing Authority: អ HHS អ NRC អ DOT – Specify DOT Agency: អ FMCSA អ FAA អ FRA អ FTA អ PHMSA អ USCG

E. Reason for Test: អ Pre-employment អ Random អ Reasonable Suspicion Cause អ Post Accident អ Return to Duty អ Follow-up អ Other (specify) ____________________________

F. Drug Tests to be Performed: អ THC, COC, PCP, OPI, AMP អTHC & COC Only អ Other (specify) ________________________________________________

OMB No. 0930-0158

PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

B. MRO Name, Address, Phone and Fax No.A. Employer Name, Address, I.D. No.

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

LAB ACCESSION NO.

SPECIMEN ID NO.

STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY

MDMA

Methamphetamine6- Acetylmorphine

Marijuana Metabolite (U9-THCA)

POSITIVE for:NEGATIVE

REJECTED FOR TESTING ADULTERATED SUBSTITUTED INVALID RESULT

PCP Codeine

MDEA

Morphine Amphetamine

MDA

DILUTE

Cocaine Metabolite (BZE)

STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY

(Print) Certifying Scientist's Name (First, MI, Last) Date (Mo./Day/Yr.)Signature of Certifying Scientist

Date (Mo./Day/Yr.)

(Print) Certifying Scientist's Name (First, MI, Last)Signature of Certifying Scientist

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.

Primary Specimen

Bottle Seal Intact

RECEIVED AT LAB OR IITF:

Date (Mo./Day/Yr.)(Print) Collector's Name (First, MI, Last)

Date (Mo./Day/Yr.)

(Print) Accessioner’s Name (First, MI, Last)

Time of Collection

Signature of Collector

Signature of Accessioner

I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was

collected, labeled, sealed, and released to the Delivery Service noted in accordance with applicable Federal requirements.

REMARKS

Temperature between 90° and 100° F? អ Yes អ No, Enter Remark Collection: អ Split អ Single អ None Provided, Enter Remark

អ Observed, (Enter Remark)

REMARKS:

Test Facility (if different from above):

800-877-7484

SPECIMEN BOTTLE(S) RELEASED TO:

Name of Delivery Service

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.

RReevviisseedd 1100//1100..

SC2K - 111192.

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

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

SPECIMEN BOTTLE(S) RELEASED TO:

អYes អ No

If No, Enter remarks

in Step 5A.

___________________________________________

Laboratory Name

___________________________________________

Laboratory Address

អ RECONFIRMED អ FAILED TO RECONFIRM - REASON ____________________________________________

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.

អ Quest Diagnostics Courier

អ FedEx

អ Other

G. Collection Site Name: Collection Site Code:

Address:

City, State and Zip:

Collector Phone No.:

Collector Fax No.:

↓ Drug Screen

File Properties

Fact Name	Description
Form Purpose	This form is used for federal drug testing, ensuring proper handling and documentation of urine specimens.
Governing Authority	The form is governed by federal regulations established by the Department of Health and Human Services (HHS).
Collector Responsibilities	The collector must ensure the specimen's temperature is recorded within four minutes of collection.
Specimen Identification	Each specimen is assigned a unique ID number, which is crucial for tracking and chain of custody.
Testing Authority	Testing can be conducted under various authorities, including HHS, NRC, and DOT, depending on the employer's requirements.
Testing Reasons	Common reasons for testing include pre-employment, random selection, reasonable suspicion, and post-accident scenarios.
Drug Panel	The form allows for testing of various substances, including THC, cocaine, PCP, and amphetamines.
Chain of Custody	Proper chain of custody procedures must be followed to ensure the integrity of the specimen from collection to testing.
Reporting Results	Results are reported as negative, positive, or invalid, with specific remarks required for each outcome.

Instructions on Utilizing Drug Screen

Filling out the Drug Screen form is a straightforward process that requires attention to detail. After completing the form, it will be used for the testing procedure, ensuring compliance with federal requirements.

Begin with the section labeled "COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE." Fill in the following details:

Employer Name, Address, and I.D. No.
MRO Name, Address, Phone, and Fax No.
Donor SSN or Employee I.D. No.
Specify Testing Authority (HHS, NRC, DOT) and the appropriate DOT Agency if applicable.
Indicate the Reason for Test (e.g., Pre-employment, Random, etc.).
List the Drug Tests to be Performed.
Provide the Collection Site Name, Code, Address, and Collector's Phone Number.

Next, the Collector should complete their section:

Read the specimen temperature within 4 minutes. Mark if the temperature is between 90° and 100° F.
Specify the type of Collection (Split, Single, None Provided) and make remarks if needed.

The Collector must affix bottle seals to the specimen bottles, date them, and have the Donor initial the seals.
In the Chain of Custody section, the Collector certifies that the specimen was collected and sealed according to regulations. The Collector must sign and date this section.
Upon arrival at the lab, the Accessioner will confirm the receipt of the specimen. They will indicate if the bottle seal is intact and provide their signature and date.
Complete the Primary Specimen Report section, indicating whether the test results are Negative or Positive, and provide any relevant remarks.
If split testing is required, the Split Testing Laboratory will complete their section and certify the results.

Important Facts about Drug Screen

What is the purpose of the Drug Screen form?

The Drug Screen form is designed to document the collection and testing of a specimen for the presence of drugs. It serves as a record of the entire process, ensuring that the testing is conducted according to federal regulations. This form is crucial for maintaining the integrity of the testing process and protecting the rights of the donor.

Who is responsible for completing the Drug Screen form?

The form must be completed by a collector or an employer representative. This individual is responsible for ensuring that all required information is accurately filled out, including details about the employer, the Medical Review Officer (MRO), and the donor. Proper completion of the form is essential for the validity of the drug testing process.

What information is required on the Drug Screen form?

The Drug Screen form requires several key pieces of information. This includes the employer's name and address, the MRO's contact details, the donor's Social Security Number or employee ID, the testing authority, the reason for the test, and the specific drugs to be tested. Additionally, details about the collection site and the collector's information must be provided.

How is the chain of custody maintained during the drug testing process?

Chain of custody is maintained by following strict procedures throughout the collection and testing process. The collector documents the handling of the specimen, seals the specimen bottle, and ensures it is securely transported to the testing facility. Each step is recorded on the form to guarantee that the specimen remains untampered with and that its integrity is preserved.

What happens if a specimen tests positive?

If a specimen tests positive, the results will be reported on the Drug Screen form. The testing facility will indicate the specific substances detected, and the results will be categorized as negative, positive, dilute, adulterated, substituted, or invalid. If a positive result occurs, further actions may be taken, including a split specimen test to confirm the findings.

How can individuals appeal or contest a drug test result?

Individuals who wish to contest a drug test result should first contact the MRO listed on the Drug Screen form. The MRO can provide guidance on the process for disputing the results. It may involve requesting a retest of the split specimen or providing additional information that could affect the interpretation of the results.

Common mistakes

Filling out the Drug Screen form accurately is crucial for ensuring a smooth testing process. One common mistake is failing to provide complete information in the Employer Name, Address, and I.D. No. section. Incomplete details can lead to confusion and delays in processing.

Another frequent error occurs when the Donor SSN or Employee I.D. No. is not filled out correctly. This information is essential for identifying the individual being tested. Omitting or miswriting this number can result in significant issues with tracking the test results.

People often forget to specify the Testing Authority accurately. Selecting the wrong agency, such as HHS or DOT, can complicate the testing process and may lead to non-compliance with regulations.

It is also common to see mistakes in the Reason for Test section. Individuals may choose an incorrect option, such as marking "Random" when the test is actually for "Post Accident." Such errors can affect the interpretation of results and the overall testing procedure.

Additionally, errors in the Drug Tests to be Performed section can create problems. Not specifying the correct drugs or selecting "Other" without clarification can lead to confusion during the testing process.

Another mistake involves the Collector Phone No. and Collector Fax No.. Omitting these contact details can hinder communication between the testing facility and the employer, causing delays in result reporting.

People sometimes neglect to document the specimen temperature within the required time frame. The temperature must be recorded within four minutes, and failing to do so can raise questions about the validity of the sample.

Collectors may also forget to date the seal on the specimen bottles. This date is important for maintaining the chain of custody and ensuring that the sample has not been tampered with.

Another common oversight is not having the donor initial the seal. This step is crucial for confirming that the donor acknowledges the collection process and the integrity of the sample.

Finally, mistakes can occur in the Chain of Custody section. If the collector does not follow the proper procedure for releasing the specimen, it can lead to issues with the test results being accepted by regulatory bodies.

Documents used along the form

When conducting drug screenings, several other forms and documents are commonly used alongside the Drug Screen form. Each of these documents plays a vital role in ensuring the process is thorough and compliant with regulations. Below is a list of these forms, along with a brief description of each.

Chain of Custody Form: This document tracks the handling of the specimen from the time it is collected until the test results are reported. It ensures that the sample remains secure and unaltered throughout the testing process.
Consent Form: The consent form is signed by the donor, granting permission for the drug test to be conducted. It outlines the purpose of the test and the substances being screened.
Medical Review Officer (MRO) Report: This report is generated by the MRO after reviewing the test results. It provides an interpretation of the findings, especially in cases of positive results, considering any legitimate medical explanations.
Test Facility Report: This document contains the results of the drug test, including whether the sample was negative or positive for specific substances. It is essential for record-keeping and compliance.
Employer Notification Form: This form is used by the testing facility to inform the employer of the test results. It ensures that the employer receives timely and accurate information regarding the donor’s test status.
Follow-Up Testing Form: If a donor tests positive, this form outlines the procedures for follow-up testing. It ensures that further testing is conducted in a structured manner.
Quality Control Documentation: This includes records that verify the accuracy and reliability of the testing process. It ensures that all procedures meet established standards and regulations.

These documents work together to create a comprehensive framework for drug testing, ensuring that the process is fair, transparent, and compliant with legal requirements. Understanding each form's purpose helps all parties involved navigate the drug screening process effectively.

Similar forms

The Drug Screen form is a crucial document in the drug testing process, particularly in employment settings. Several other documents share similarities with this form, each serving specific functions in various testing and compliance scenarios. Below is a list of seven documents that are comparable to the Drug Screen form, along with explanations of their similarities.

Chain of Custody Form: Like the Drug Screen form, this document ensures that the specimen is tracked throughout the testing process. It outlines who collected the sample, when it was collected, and how it was transported, maintaining a clear record to prevent tampering.
Medical Review Officer (MRO) Report: This report is similar in that it communicates the results of the drug test. It includes the interpretation of results and any necessary follow-up actions, ensuring that the employer receives accurate information about the employee's drug test status.
Consent Form: A consent form is necessary for legal reasons, just like the Drug Screen form. It confirms that the donor has agreed to the testing process, providing a legal basis for the collection and analysis of the specimen.
Employee Handbook: While not a testing document per se, the employee handbook often includes drug testing policies. This is similar to the Drug Screen form in that it outlines the procedures and consequences related to drug testing within an organization.
Incident Report Form: This form is used when an accident occurs, similar to how the Drug Screen form may be utilized in post-accident testing. Both documents serve to document events and ensure compliance with safety regulations.
Laboratory Analysis Report: This report details the findings from the drug test, akin to the results section of the Drug Screen form. It provides specific information about the substances tested and the outcomes, ensuring transparency in the testing process.
Return-to-Duty Form: This document is similar because it outlines the steps an employee must take to return to work after a positive drug test. It often references the results and conditions set forth in the Drug Screen form, ensuring a clear path for compliance and safety.

Dos and Don'ts

When filling out the Drug Screen form, attention to detail is crucial. Here are ten important dos and don’ts to keep in mind to ensure a smooth and accurate process.

Do ensure all required fields are completed accurately, including your name and identification number.
Do specify the testing authority clearly, whether it’s HHS, NRC, or DOT.
Do indicate the reason for the test, such as pre-employment or post-accident.
Do check that the specimen temperature is recorded within the specified time frame.
Do sign and date the form where required to confirm the information is correct.

Don’t leave any fields blank; incomplete forms can lead to delays or rejections.
Don’t use any abbreviations that may cause confusion; clarity is essential.
Don’t alter any information after it has been entered; this can compromise the integrity of the test.
Don’t forget to provide your contact information in case follow-up is necessary.
Don’t neglect to review the entire form before submission to catch any errors.

By following these guidelines, you can help ensure that your Drug Screen form is filled out correctly, minimizing the risk of complications. Remember, accuracy and honesty are key in this process.

Misconceptions

Misconception 1: The Drug Screen form is only used for employment purposes.

While many associate drug screening primarily with pre-employment tests, the form serves multiple purposes. It can be utilized for random testing, post-accident evaluations, and follow-up tests, among others.

Misconception 2: Only illegal drugs are tested.

The Drug Screen form covers a range of substances, including prescription medications. Tests often check for substances such as THC, cocaine, and amphetamines, which may include both illegal drugs and legal prescriptions.

Misconception 3: A positive result automatically leads to termination.

A positive drug test does not guarantee termination. Employers typically follow established protocols, which may involve further testing or a review of the circumstances before making employment decisions.

Misconception 4: The temperature of the specimen is irrelevant.

The temperature of the specimen is a crucial factor in verifying its authenticity. A temperature reading between 90° and 100° F indicates that the sample is likely valid, while readings outside this range may raise concerns about tampering.

Misconception 5: The Drug Screen form is the same across all states.

Although there are federal guidelines, variations exist among states regarding the use and requirements of drug screening forms. Employers must adhere to both federal and state regulations.

Misconception 6: Donors can refuse to provide a specimen.

While individuals may express their refusal, employers often have policies that require compliance with testing. Refusal can lead to disciplinary actions, including termination, depending on the organization’s policies.

Misconception 7: All testing facilities follow the same procedures.

Testing facilities may have different protocols for handling specimens and conducting tests. However, they must comply with federal requirements, which can lead to variations in practice.

Misconception 8: Chain of custody is not important.

The chain of custody is critical in ensuring the integrity of the specimen. Proper documentation and handling help prevent tampering and ensure that the results are reliable and admissible in legal contexts.

Misconception 9: The Drug Screen form is only relevant for employers.

This form is also significant for employees and donors. Understanding the process and implications of drug testing can help individuals navigate their rights and responsibilities effectively.

Key takeaways

When filling out and using the Drug Screen form, keep the following key points in mind:

Complete All Sections: Ensure that every section of the form is filled out accurately, including employer information, donor details, and testing authority.
Specify the Reason for Testing: Clearly indicate why the test is being conducted, whether it’s for pre-employment, random testing, or another reason.
Record Drug Tests to be Performed: List the specific drugs that will be tested, such as THC, COC, or PCP.
Temperature Check: The collector must check the specimen temperature within four minutes. Confirm it falls between 90° and 100° F.
Chain of Custody: Follow proper chain of custody procedures to maintain the integrity of the specimen from collection to testing.
Affix Seals: The collector should seal the specimen bottles properly and ensure both the collector and donor initial the seals.
Report Results: After testing, results must be reported accurately, indicating whether the specimen was negative, positive, or rejected for testing.
Keep Copies: Make sure to retain copies of the completed form for record-keeping and compliance purposes.

By following these guidelines, you can ensure a smooth process when using the Drug Screen form.