Photocopy For ICup Employee Drug Ing Kits 2400 Kit I Cup

User Manual: 2400

Open the PDF directly: View PDF PDF.
Page Count: 2

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
Specic
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
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

Navigation menu