INITIAL TEST RESULTS - Employee Drug Testing Ace

1 URINE INITIAL drug SCREEN RESULT FORMD aytime Phone:Evening Phone:Date of Birth:(Print) Donor s Name (First, MI, Last)Date (Mo/Day/Yr)Date (Mo/Day/Yr)XSignature of DonorSTEP 2: COMPLETED BY DONORDONOR 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 VERIFIED BY: PHOTO ID q EMPLOYER REP. qDONOR SSN, DRIVER S LICENSECOLLECTION SITE / COMPANY NAMENAMEADDRESS SUITECITY STATE POSTAL CODEPHONE FAXor Employee FOR TEST: Pre Employment Random Reasonable Suspicion / Cause Post Accident Return to Duty Follow Up Otherq q q q q q q _____COLLECTOR NAME (PRINT)Collector Phone No.

2 (_____) _____Collector Fax No. (_____) _____DONOR NAME:STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVELast:First:STEP 4: COLLECTOR CERTIFICATIONCOLLECTOR CERTIFICATION: accordance with applicable of Collector(Print) Collector s Name (First, MI, Last)Time of CollectionDate (Mo/Day/Yr)Specimen ID NumberSTEP 3: COMPLETED BY COLLECTOR INITIAL TEST RESULTSS creen performed by:Date:Remarks: PRESUMPTIVE NOTDRUG NAME 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 DEVICESPECIMEN VALIDITY TEST RESULTS preliminary RESULTS (If different than collector)(See color chart and package insert for interpretation)Lot #:Exp.

3 Date:XRead specimen temperature within (4) minutes. Specimen within range:q Yes, 90 - 100 F (32 - 38 C)q No, record specimen temperature herePRESS HARD - YOU ARE MAKING MULTIPLE COPIESTO BE COMPLETED BY COLLECTORTO BE COMPLETED BY [ ] Abnormal[ ] Not Tested[ ] Normal[ ] Abnormal[ ] Not Tested[ ] Normal[ ] Abnormal[ ] Not Tested[ ] Normal[ ] Abnormal[ ] Not Tested[ ] Normal[ ] Abnormal[ ] Not Tested[ ] Normal[ ] Abnormal[ ] Not TestedSpeci cGravityNitriteCreatinineGLpHPN: 2380 2009. Inverness Medical. All rights