Photocopy For ICup Employee Drug Ing Kits 2400 Kit I Cup
User Manual: 2400
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Page Count: 2
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URINE INITIAL DRUG SCREEN RESULT FORM
Daytime Phone: Evening Phone: Date of Birth:
(Print) Donor’s Name (First, MI, Last) Date (Mo/Day/Yr)
Date (Mo/Day/Yr)
X
Signature of 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
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.
ID VERIFIED BY: PHOTO ID q EMPLOYER REP. q
DONOR SSN, DRIVER’S LICENSE
COLLECTION SITE / COMPANY NAME
NAME
ADDRESS SUITE
CITY STATE POSTAL CODE
PHONE FAX
or EMPLOYEE I.D. NO.
REASON FOR TEST: Pre Employment Random Reasonable Suspicion / Cause Post Accident Return to Duty Follow Up Other
q q q q q q q ____________________________________________
COLLECTOR NAME Collector Phone No. (__________) _____________________________________
Collector Fax No. (__________) _____________________________________
DONOR NAME:
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
Last: First:
STEP 4: COLLECTOR CERTIFICATION
COLLECTOR CERTIFICATION: accordance with applicable requirements.
X
X
Signature of Collector
(Print) Collector’s Name (First, MI, Last)
Time of Collection
Date (Mo/Day/Yr)
STEP 3: COMPLETED BY COLLECTOR — INITIAL TEST RESULTS
PRESUMPTIVE NOT
DRUG NAME
DONOR RESULTS SHOWN ABOVE
ALCOHOL SCREEN (If Performed)
NEG POSITIVE TESTED
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) [ ] [ ] [ ]
Propoxyphene (PPX) [ ] [ ] [ ]
Results [ ] [ ] [ ]
Tricyclic Antidepressants (TCA) [ ] [ ] [ ]
Other [ ] [ ] [ ]
ON-SITE SCREENING DEVICE
SPECIMEN VALIDITY TEST RESULTS
preliminary results
(If different than collector)
(See color chart and package insert for interpretation)
Lot #:
Screen performed by:
Remarks:
Exp. Date:
Date:
X
TO BE COMPLETED BY COLLECTOR TO BE COMPLETED BY DONOR
Oxidant
OX
S.G.
pH
Ni
GL
CR
Normal
[ ]
Abnormal
[ ]
Not Tested
[ ]
Normal
[ ]
Abnormal
[ ]
Not Tested
[ ]
Normal
[ ]
Abnormal
[ ]
Not Tested
[ ]
Normal
[ ]
Abnormal
[ ]
Not Tested
[ ]
Normal
[ ]
Abnormal
[ ]
Not Tested
[ ]
Normal
[ ]
Abnormal
[ ]
Not Tested
Specic
Gravity
Nitrite
Creatinine
GL
pH
(PRINT)
Read specimen temperature within (4) minutes. Specimen within range:
q
Yes, 90º - 100ºF (32º - 38ºC)
q
No, record specimen temperature here
Specimen ID Number
PN: 2400© 2009. Inverness Medical. All rights reserved.
TM
http://www.employee-drug-testing-ace.com/employment-drug-screening-resources/employee-drug-screening-and-testing-library
Print Form
Submit by Email
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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