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The Drug Screen form, officially known as the Federal Drug Testing Custody and Control Form, plays a crucial role in the drug testing process across various sectors. This form is meticulously designed to ensure that all necessary information is captured for effective drug testing, adhering to federal regulations. It includes sections for the employer’s name and address, as well as details about the Medical Review Officer (MRO) responsible for overseeing the testing process. The form also requires identification of the donor, whether by Social Security Number or Employee ID, and specifies the testing authority, such as the Department of Transportation (DOT) or the Department of Health and Human Services (HHS). Various reasons for testing—ranging from pre-employment screenings to post-accident evaluations—are outlined, allowing for clarity in the purpose of each test. Additionally, the form indicates which specific drug tests will be performed, such as those for THC or cocaine metabolites. Collectors are tasked with documenting the temperature of the specimen and ensuring proper chain of custody, which is vital for maintaining the integrity of the testing process. Each step, from specimen collection to laboratory analysis, is carefully recorded to uphold the standards set by federal requirements. This form not only facilitates compliance but also serves as a comprehensive record that protects the rights of both the employer and the employee throughout the testing procedure.

Preview - Drug Screen Form

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

800-877-7484

SPECIMEN ID NO.

 

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

LAB ACCESSION 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.

A. Employer Name, Address, I.D. No.

 

 

B. MRO Name, Address, Phone and Fax No.

 

 

 

 

 

 

 

 

 

C. Donor SSN or Employee I.D. No. _______________________________________________________________

 

 

 

 

D. SpecifyTesting Authority: ￿ HHS

￿ NRC

￿ DOT – Specify DOT Agency: ￿ FMCSA

￿ FAA

￿ FRA ￿ FTA ￿ PHMSA ￿ USCG

E. Reason forTest: ￿ Pre-employment

￿ Random

￿ Reasonable Suspicion Cause ￿ Post Accident

￿ Return to Duty

￿ Follow-up ￿ Other (specify) ____________________________

F. DrugTests to be Performed:

￿ THC, COC, PCP, OPI, AMP

￿THC & COC Only

￿ Other (specify) ________________________________________________

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

STEP 3: Collector affixes bottle seal(s) to bottle(s). 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

 

 

 

 

 

￿ Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

(Print) Collector's Name (First, MI, Last)

Date (Mo./Day/Yr.)

 

Time of Collection

 

 

Name of Delivery Service

RECEIVED AT LAB OR IITF:

 

 

 

 

 

Primary Specimen

SPECIMEN BOTTLE(S) RELEASED TO:

 

X

 

 

 

 

 

Bottle Seal Intact

 

 

 

 

 

 

 

￿ Yes ￿ No

 

 

 

Signature of Accessioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If No, Enter remarks

 

 

 

 

 

 

 

 

 

in Step 5A.

 

 

 

(Print) Accessioner’s Name (First, MI, Last)

 

 

 

Date (Mo./Day/Yr.)

 

STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY

NEGATIVE

POSITIVE for:

Marijuana Metabolite ( 9-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 (Mo./Day/Yr.)

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

procedures, analyzed and reported in accordance with applicable Federal requirements.

 

 

 

 

 

 

 

 

 

 

 

 

Laboratory Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Certifying Scientist

 

 

 

(Print) Certifying Scientist's Name (First, MI, Last)

Date (Mo./Day/Yr.)

 

 

 

 

 

 

 

Laboratory Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OMB No. 0930-0158

PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

Document Specifics

Fact Name Description
Form Title The document is officially titled the "Federal Drug Testing Custody and Control Form."
Contact Information A customer service number is provided: 800-877-7484 for inquiries.
Specimen ID Each specimen is assigned a unique ID number for tracking purposes.
Testing Authority Tests can be authorized by HHS, NRC, or DOT, with specific agencies listed under DOT.
Reason for Testing Various reasons for testing are allowed, including pre-employment, random, and post-accident.
Drug Tests Tests can include substances such as THC, cocaine, PCP, and amphetamines, among others.
Chain of Custody The collector must ensure proper chain of custody from collection to testing facility.
Compliance This form is governed by federal regulations, ensuring compliance with applicable laws.

Drug Screen: Usage Instruction

Filling out the Drug Screen form is an essential step in the testing process. After completing this form, the necessary information will be gathered to ensure compliance with federal requirements. Follow the steps outlined below to accurately complete the form.

  1. Begin by entering the Employer Name, Address, and I.D. No. in section A.
  2. In section B, provide the MRO Name, Address, Phone, and Fax No.
  3. Next, fill in the Donor SSN or Employee I.D. No. in section C.
  4. Specify the Testing Authority in section D by checking the appropriate box (HHS, NRC, DOT) and indicating the DOT Agency if applicable.
  5. In section E, select the Reason for Test by checking one of the options provided, or specify another reason.
  6. Section F requires you to indicate the Drug Tests to be Performed. Check the appropriate boxes or specify other tests.
  7. Complete section G by providing the Collection Site Name, Collection Site Code, Address, Collector Phone No., City, State, and Zip, as well as the Collector Fax No.
  8. In step 2, the Collector should read the specimen temperature within 4 minutes and confirm if it is between 90° and 100° F. Mark 'Yes' or 'No' and enter remarks as necessary.
  9. Indicate the type of collection (Split, Single, None Provided, or Observed) and enter any remarks.
  10. In step 3, the Collector affixes the bottle seal(s) to the bottle(s), dates the seal(s), and has the donor initial the seal(s). The donor then completes step 5 on Copy 2.
  11. Step 4 involves the Collector certifying that the specimen was collected, labeled, sealed, and released in accordance with federal requirements. The Collector must sign and provide their name, date, and time of collection.
  12. Complete the section for SPECIMEN BOTTLE(S) RELEASED TO, confirming if the bottle seal is intact.
  13. Step 5A is where the Test Facility completes the Primary Specimen Report. Indicate if the result is negative, positive, or rejected for testing and provide remarks if necessary.
  14. Finally, the Certifying Scientist must sign and print their name, along with the date of certification.
  15. If applicable, step 5B is completed by the Split Testing Laboratory, confirming the results and providing the necessary signatures and details.

Learn More on Drug Screen

What is the purpose of the Drug Screen form?

The Drug Screen form is used to document the process of collecting and testing a specimen for drugs. It ensures that all steps are followed according to federal regulations, maintaining the integrity of the testing process. This form is essential for employers who conduct drug testing for various reasons, including pre-employment screenings and random testing.

Who completes the Drug Screen form?

The form is primarily completed by the collector or employer representative. They fill out the necessary details, including the donor's information, testing authority, and reasons for testing. This information is crucial for proper identification and tracking of the specimen throughout the testing process.

What information is required on the form?

Several key pieces of information must be provided, including:

  • Employer name and address
  • Medical Review Officer (MRO) details
  • Donor's Social Security Number or Employee ID
  • Testing authority and reason for the test
  • Types of drug tests to be performed
  • Collection site information

What types of drug tests can be performed?

The form allows for various types of drug tests, including tests for substances such as THC (marijuana), cocaine, PCP, opiates, and amphetamines. Depending on the requirements, employers can specify the exact tests needed on the form.

How is the specimen collected?

Specimen collection involves the collector ensuring that the specimen is collected under controlled conditions. The collector checks the temperature of the specimen within four minutes of collection to ensure it falls within the acceptable range. This step helps to confirm that the specimen is valid and has not been tampered with.

What is the chain of custody?

The chain of custody is a critical part of the drug testing process. It documents the handling of the specimen from the time it is collected until it is tested in the laboratory. This procedure ensures that the specimen is not altered or contaminated during transport and testing, thereby maintaining its integrity.

What happens if the test results are positive?

If the test results are positive, the form will indicate the specific substances detected. The Medical Review Officer (MRO) will then review the results and may contact the donor to discuss the findings. The donor has the right to request a retest of a split specimen if one was collected.

Can the form be used for different testing authorities?

Yes, the Drug Screen form can be used for various testing authorities, including the Department of Transportation (DOT) and Health and Human Services (HHS). The specific authority should be indicated on the form, as different regulations may apply depending on the authority overseeing the testing.

What should I do if I notice an error on the form?

If an error is identified on the form, it is important to correct it as soon as possible. The collector should make the necessary corrections and initial them to indicate that they have been reviewed. Accurate documentation is essential for the validity of the test results.

How is the confidentiality of the results maintained?

Confidentiality is a priority in the drug testing process. The results are typically shared only with authorized personnel, such as the employer and the MRO. The form includes sections that ensure sensitive information is handled appropriately, safeguarding the donor's privacy.

Common mistakes

Filling out the Drug Screen form can seem straightforward, but many people make common mistakes that can lead to delays or issues with testing. Here are eight mistakes to watch out for when completing the form.

One frequent error is forgetting to include the donor’s Social Security Number or Employee ID. This information is crucial for identifying the individual being tested. If this section is left blank, it can cause significant delays in processing the test.

Another common mistake involves not specifying the testing authority. The form requires you to choose from options like HHS, NRC, or DOT. Omitting this detail can lead to confusion about which regulations apply to the test.

People often fail to indicate the reason for the test. Whether it’s for pre-employment, random testing, or another reason, this information is essential. Leaving it blank can raise questions and complicate the testing process.

Choosing the correct drug tests to be performed is also vital. Some individuals mistakenly select "Other" without specifying the drugs. This can lead to misunderstandings about what substances are being tested, potentially affecting the outcome.

Another mistake is not providing complete information about the collection site. Ensure that the name, code, address, and contact details are accurate. Incomplete information can lead to logistical issues when transporting the specimen.

Collectors must read the specimen temperature within four minutes, but sometimes they forget to mark this on the form. If the temperature falls outside the acceptable range, it’s crucial to note this with appropriate remarks to avoid complications.

Failing to properly complete the chain of custody section can also cause problems. This section must be filled out accurately to ensure the integrity of the specimen. Any discrepancies can lead to questions about the reliability of the test results.

Lastly, some people neglect to have the collector and donor sign the necessary sections. Signatures are vital for verifying that all procedures were followed. Without them, the form may be considered incomplete, resulting in delays or rejections.

By being mindful of these common mistakes, individuals can help ensure that the Drug Screen form is filled out correctly, facilitating a smoother testing process.

Documents used along the form

When conducting drug screenings, several other forms and documents are often required to ensure a smooth and compliant process. Each document plays a critical role in maintaining accuracy, accountability, and adherence to regulations. Below is a list of common forms associated with the Drug Screen form.

  • Chain of Custody Form: This document tracks the handling of the specimen from collection to analysis, ensuring that it remains uncontaminated and legally defensible.
  • Consent Form: The donor must sign this form to authorize the drug test. It confirms their understanding of the process and the implications of testing.
  • Laboratory Test Request Form: This form is submitted to the testing facility and specifies the tests to be performed on the specimen, including any specific drugs to be analyzed.
  • Results Report: After testing, this document provides the outcomes of the analysis, indicating whether the specimen tested negative or positive for specific substances.
  • Medical Review Officer (MRO) Report: An MRO evaluates the test results and may provide insights into any medical explanations for positive results, ensuring a fair review process.
  • Employee Handbook Addendum: This document outlines the company's drug testing policies and procedures, ensuring that employees are aware of expectations and consequences.
  • Incident Report Form: If a drug test is conducted due to an incident (like an accident), this form documents the details of the event, which may be relevant for the testing process.
  • Follow-Up Testing Authorization Form: If an employee tests positive, this form is used to authorize any required follow-up testing as part of the return-to-duty process.

Each of these forms is essential in ensuring that the drug screening process is conducted fairly, legally, and effectively. It is crucial to keep these documents organized and readily available to streamline the process and ensure compliance with applicable regulations.

Similar forms

The Federal Drug Testing Custody and Control Form shares similarities with the Medical Release Form, commonly used in healthcare settings. Both documents require specific personal information about the individual, such as their name and identification number. Just as the Drug Screen form outlines the reasons for testing, the Medical Release Form often details the purpose of sharing medical information. Each form emphasizes the importance of confidentiality and proper handling of sensitive information, ensuring that both the donor and the healthcare provider understand the implications of the data being collected and shared.

Another document that resembles the Drug Screen form is the Chain of Custody Form used in legal contexts. This form is crucial in maintaining the integrity of evidence, much like how the Drug Screen form ensures the integrity of the specimen collected. Both documents include sections for signatures and timestamps, which confirm the handling and transfer of the specimen or evidence. The Chain of Custody Form, like the Drug Screen form, highlights the importance of following strict procedures to avoid any tampering or contamination, thereby ensuring that the results remain valid and reliable.

The Consent Form for Medical Testing also parallels the Drug Screen form in its purpose of obtaining permission from the individual being tested. Both documents require clear communication about what the testing entails and what the results may imply. Just as the Drug Screen form specifies the types of drugs being tested, the Consent Form details the tests being performed and any potential risks involved. This transparency is essential for fostering trust between the individual and the testing entity, as both parties must agree to the terms before proceeding.

Similarly, the Employee Health Screening Form shares characteristics with the Drug Screen form, particularly in the context of workplace health and safety. Both forms collect personal information and require the individual to provide consent for testing. The Employee Health Screening Form often includes questions about medical history and current health status, akin to how the Drug Screen form gathers information about the testing authority and reasons for testing. Both documents aim to promote a safe and healthy work environment by ensuring that employees are fit for duty.

Lastly, the Incident Report Form has a connection to the Drug Screen form, especially in situations where substance use may be a factor in an incident. Both documents document specific details surrounding an event, whether it be a drug test or an accident. The Incident Report Form includes information about the individuals involved, the circumstances of the incident, and any immediate actions taken, similar to how the Drug Screen form records the collection process and results. Each form serves as an official record, helping organizations to analyze situations and implement necessary changes to prevent future occurrences.

Dos and Don'ts

When filling out the Drug Screen form, it is important to follow certain guidelines to ensure accuracy and compliance. Here are five things you should and shouldn't do:

  • Do double-check all personal information, including your name and identification numbers, to avoid any errors.
  • Don't leave any required fields blank; incomplete forms may lead to delays or issues with testing.
  • Do specify the reason for the test clearly, whether it is for pre-employment, random testing, or another reason.
  • Don't provide inaccurate or misleading information about your drug history; honesty is crucial.
  • Do ensure that the collector properly seals the specimen bottle and that you initial the seal as required.

Following these guidelines will help ensure a smooth process during drug testing.

Misconceptions

Misconceptions about the Drug Screen form can lead to confusion and misunderstandings. Below are seven common misconceptions, along with clarifications to help individuals better understand the purpose and process of this important document.

  1. The Drug Screen form is only for new employees. Many believe this form is solely used for pre-employment testing. In reality, it is also utilized for random tests, reasonable suspicion, post-accident situations, and follow-up testing.
  2. Only certain drugs are tested. While some may think that only a few substances are screened, the form allows for a variety of drugs to be tested, including THC, cocaine, PCP, opiates, and amphetamines. Employers can specify which tests to perform based on their needs.
  3. The collector does not need to document anything. Some may assume that the collection process is informal. However, the collector is required to document various details, including the specimen temperature, collection method, and any remarks that may be relevant to the testing process.
  4. Chain of custody is not important. A common misconception is that the chain of custody can be disregarded. This is not true. Maintaining a proper chain of custody is crucial to ensure the integrity of the specimen and the validity of the test results.
  5. A positive test result means immediate termination. Some individuals fear that a positive result will automatically lead to job loss. While a positive result can have serious consequences, employers typically follow a process that may include further testing or an opportunity to explain the result.
  6. Donors do not have rights during the testing process. There is a belief that donors have no control over the process. In fact, donors have the right to be informed about the testing procedures, request a copy of the results, and in some cases, challenge the findings.
  7. The results are always accurate. While the testing process is designed to be thorough, there can be instances of false positives or other errors. It is essential for individuals to understand that results should be interpreted carefully and in the context of additional information.

Understanding these misconceptions can help individuals navigate the drug screening process with greater confidence and clarity. It is important to approach this topic with care, recognizing the implications it may have on one’s employment and personal life.

Key takeaways

Filling out and using the Drug Screen form is a critical process that requires attention to detail. Here are some key takeaways to ensure compliance and accuracy:

  • Understand the Purpose: The Drug Screen form is used for various testing scenarios, including pre-employment, random testing, and post-accident situations.
  • Collect Accurate Information: Ensure that all sections, including the employer's and donor's details, are filled out correctly to avoid delays.
  • Specify Testing Authority: Clearly indicate the testing authority, such as HHS or DOT, and specify the relevant agency if applicable.
  • Temperature Check: The collector must check the specimen temperature within four minutes. A temperature between 90° and 100° F is acceptable.
  • Chain of Custody: Maintain a clear chain of custody. This means documenting every step of the process, from collection to laboratory receipt.
  • Sealing Procedures: The collector should affix bottle seals, date them, and ensure the donor initials the seals to confirm integrity.
  • Testing Results: Understand the different outcomes, such as negative, positive, or rejected for testing, and what each result implies.
  • Split Testing: If a split specimen is required, ensure that the second sample is handled with the same care as the primary specimen.
  • Document Everything: Keep thorough records, including signatures and dates, throughout the process to ensure compliance with federal requirements.

By following these guidelines, you can navigate the Drug Screen form process effectively and responsibly.