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Federal Drug Testing Custody and Control Form

URINE ORAL FLUID. In accordance with applicable federal requirements, my verification is: NEGATIVE POSITIVE for: DILUTE REFUSAL . TO TEST because – check reason(s) below: TEST. CANCELLED ADULTERATED(adulterant/reason): SUBSTITUTED OTHER: REMARKS: / / Signature of Medical Revie. w Offc r (PRINT) Medical Revie. w Offc r’

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