1 FEDERAL drug TESTING CUSTODY AND CONTROL FORM. 800-877-7484. 80283219 SPECIMEN ID NO. STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE LAB ACCESSION NO. OMB No. 0930-0158. A. Employer Name, Address, No. B. MRO Name, Address, Phone and Fax 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. AWSI / BAKER HUGHES INC EMRO - Dr. Steve Kracht ANGELICA ROBERTS 7500 W 110th St. Ste 500. 17542 E 17TH ST STE 330 PO Box 25903. TUSTIN, CA 92780 Overland Park, KS 66225. PH: 713-466-2936 FAX: 713-466-2920 Ph: 888-382-2281 Fax: 913-469-4029. C. Donor SSN or Employee No. _____.
2 D. Specify TESTING Authority: HHS NRC DOT Specify DOT Agency: FMCSA FAA FRA FTA PHMSA USCG. E. Reason for Test: Pre-employment Random Reasonable Suspicion Cause Post Accident Return to Duty Follow-up Other (specify) _____. F. drug Tests to be Performed: THC, COC, PCP, OPI, AMP THC & COC Only Other (specify) _____. ( ) 7643N DOT 5 Panel 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. PRESS HARD - YOU ARE MAKING MULTIPLE COPIES. STEP 3: Collector affixes bottle seal(s) to bottle(s).
3 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 AM. Other PM. (Print) Collector's Name (First, MI, Last) Date ( ) Time of Collection Name of Delivery Service RECEIVED AT LAB OR IITF: Primary Specimen SPECIMEN BOTTLE(S) RELEASED TO: Bottle Seal Intact X. Signature of Accessioner Yes No If No, Enter remarks (Print) Accessioner's Name (First, MI, Last) Date ( ) in Step 5A.
4 STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY. NEGATIVE POSITIVE for: Marijuana Metabolite (U9-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. X. Signature of Certifying Scientist (Print) Certifying Scientist's Name (First, MI, Last) Date ( ). 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 Laboratory Name procedures, analyzed and reported in accordance with applicable FEDERAL requirements.
5 _____ X. Laboratory Address Signature of Certifying Scientist (Print) Certifying Scientist's Name (First, MI, Last) Date ( ).