Photocopy For ICup Employee Drug Ing Kits 2400 Kit I Cup
User Manual: 2400
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Submit by Email Print Form URINE INITIAL DRUG SCREEN RESULT FORM TM Specimen ID Number STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE COLLECTION SITE / COMPANY NAME ADDRESS SUITE CITY STATE PHONE FAX POSTAL CODE DONOR SSN, DRIVER’S LICENSE or EMPLOYEE I.D. NO. ID VERIFIED BY: PHOTO ID q DONOR NAME: Last: REASON FOR TEST: COLLECTOR NAME EMPLOYER REP. q First: Pre Employment q Random q Reasonable Suspicion / Cause q Post Accident q Return to Duty q (PRINT) Read specimen temperature within (4) minutes. Specimen within range: q Yes, 90º - 100ºF (32º - 38ºC) q Follow Up q Other q ____________________________________________ Collector Phone No. (__________) _____________________________________ Collector Fax No. (__________) _____________________________________ No, record specimen temperature here tests to the health care provider. In the case of screening for employment or pre-employment, I also authorize release of the results of these tests to my employer or prospective employer and / or their authorized health care provider. X (Print) Donor’s Name (First, MI, Last) Daytime Phone: Date (Mo/Day/Yr) Evening Phone: Date of Birth: Date (Mo/Day/Yr) STEP 3: COMPLETED BY COLLECTOR — INITIAL TEST RESULTS Lot #: Screen performed by: ON-SITE SCREENING DEVICE preliminary results (If different than collector) Exp. Date: Date: X Remarks: SPECIMEN VALIDITY TEST RESULTS (See color chart and package insert for interpretation) Normal Abnormal Not Tested [ ] [ ] Specific Gravity [ ] [ ] S.G. Normal Abnormal Not Tested pH [ ] [ ] pH Normal Abnormal Not Tested Nitrite [ ] [ ] Ni Normal Abnormal Not Tested GL [ ] [ ] GL Normal Abnormal Not Tested Creatinine Normal Abnormal Not Tested [ ] [ ] Oxidant OX CR [ ] [ ] [ ] [ ] [ ] [ ] DRUG NAME Amphetamine (AMP) Barbiturates (BAR) Benzodiazepines (BZO) Buprenorphine (BUP) Cocaine (COC) Marijuana (THC) Methadone (MTD) Methamphetamine (mAMP) Ecstasy (MDMA) Opiate (OPI/MOP) Oxycodone (OXY) Phencyclidine (PCP) NEG [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] PRESUMPTIVE POSITIVE [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] NOT TESTED [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] Propoxyphene (PPX) Tricyclic Antidepressants (TCA) Other [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ALCOHOL SCREEN (If Performed) Results [ ] [ ] [ ] DONOR RESULTS SHOWN ABOVE STEP 4: COLLECTOR CERTIFICATION COLLECTOR CERTIFICATION: accordance with applicable requirements. X Signature of Collector Time of Collection X (Print) Collector’s Name (First, MI, Last) Date (Mo/Day/Yr) © 2009. Inverness Medical. All rights reserved. http://www.employee-drug-testing-ace.com/employment-drug-screening-resources/employee-drug-screening-and-testing-library PN: 2400 TO BE COMPLETED BY DONOR STEP 2: COMPLETED BY DONOR DONOR CONSENT: I certify that I provided my specimen to the collector, that the specimen container was sealed with a tamper proof seal in my presence and that the information provided on this form Signature of Donor TO BE COMPLETED BY COLLECTOR NAME Peel label and discard! Check Lid to ensure that it is secure and tight. Place Cup results side down over this opening. Press the “COPY” button on your photocopier. http://www.employee-drug-testing-ace.com/employment-drug-screening-resources/employee-drug-screening-and-testing-library
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.6 Linearized : No XMP Toolkit : Adobe XMP Core 4.0-c316 44.253921, Sun Oct 01 2006 17:14:39 Modify Date : 2010:02:05 08:31:01-08:00 Create Date : 2010:02:05 08:26:09-08:00 Metadata Date : 2010:02:05 08:31:01-08:00 Format : application/pdf Title : Photocopy Template for iCup Employee Drug Testing Kits Description : The Photocopy Template for iCup Drug Testing Kits found at www.EmployeeDrugTestAce.com differs from the 2-Part Result Form in that there is a window which allows the user to copy the drug test results from the drug test kit directly onto the form. You can find hard copies or digital form for download on our website. Hard copies are made from thick paper and the down-loadable digital versions can be filled in on the computer and are available for download on each product page or in our Resource Library. (a.k.a. www.DrugTestingAce.com and www.EDTAce.com) Creator : Employee Drug Testing Ace Subject : employee drug testing, pre-employment drug testing, pre-employment drug screening, employment drug screening, employment drug testing, employee drug screening, pre-employment drug test, employment drug testing lab, employee drug test, employee drug tests, pre employment drug testing, employee drug & alcohol testing, drug testing in the work place, drug screening for employment, drug testing at work, drug testing from work accident, post accident employee drug test, employment drug screens, drug test for employment, drug tests for work, employee pre employment drug screening, hospital employee drug testing, drug testing for employment, drug testing in work place Document ID : uuid:221c0fab-4493-4cfe-a2c5-483937342f8a Instance ID : uuid:a727e1a6-928d-4942-a31c-4f9a7fa3428f Marked : True Web Statement : http://www.employee-drug-testing-ace.com/employment-drug-testing-labs/employment-drug-testing-policies#Intellectual_Property Keywords : employee drug testing, pre-employment drug testing, pre-employment drug screening, employment drug screening, employment drug testing, employee drug screening, pre-employment drug test, employment drug testing lab, employee drug test, employee drug tests, pre employment drug testing, employee drug & alcohol testing, drug testing in the work place, drug screening for employment, drug testing at work, drug testing from work accident, post accident employee drug test, employment drug screens, drug test for employment, drug tests for work, employee pre employment drug screening, hospital employee drug testing, drug testing for employment, drug testing in work place Has XFA : Yes Page Count : 2 Author : Employee Drug Testing Ace Warning : [Minor] Ignored duplicate Info dictionaryEXIF Metadata provided by EXIF.tools