"On-Site Drug Test Results Form - Medimpex United Inc."
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1Specimen ID #
On-Site Drug Test Results Form
Company Information: (Information about the company doing the testing)
Company Name
Suite
Address
Zip
City
State
Phone/Fax
Donor Information: (Information about the person being tested)
____________________
Donor Name
SSN or ID#
_________________
Identification Type
Expiration
Test Information:
Reason for Test:
Pre Employ
Random
Post Accident
Reasonable Suspicion
Periodic
_________________
____________
__ _____
Date of Collection:
Time of Collection:
AM / PM
Specimen Type:
Oral Fluids
Urine
Temperature 90 - 100 ° F
YES
No
Lot #:
Remarks:
Certification Information: (Must be signed by both Donor and Collector)
I hereby certify that the specimen provided is my own and has not been substituted or adulterated, I further agree and
grant permission for the testing of my specimen for drug metabolites and/or alcohol. Also, I hereby give permission for the
release of the results of this test to my employer/prospective employer and/or their authorized Healthcare professionals.
Donor's Signature
Date
I hereby certify that I collected the specimen provided by the aforementioned Donor and that it was not substituted
or adulterated to the best of my knowledge. The specimen temperature and color were acceptable.
Collector's Signature
Date
Test Results: (Non-negative results must be confirmed by a Lab (using GC/MS)
Alcohol - ETG
Methadone - MTD
Adulteration
Negative for all
Amphetamines - AMP
Nicotine / Cotinine - COT
OX
Oxidant
Barbiturates - BAR
Opiates/Morphine - OPI
Specific
Positive -
for the
Buprenorphine - BUP
Oxycodone - OXY
SG
Gravity
drugs marked:
Benzodiazepine - BZO
Marijuana - THC
Cocaine - COC
Phencyclidine - PCP
pH
pH
Methamphetamine - mAMP
Propoxyphene - PPX
MDMA - MDMA
Tricyclic - TCA
Specimen ID #
On-Site Drug Test Results Form
Company Information: (Information about the company doing the testing)
Company Name
Suite
Address
Zip
City
State
Phone/Fax
Donor Information: (Information about the person being tested)
____________________
Donor Name
SSN or ID#
_________________
Identification Type
Expiration
Test Information:
Reason for Test:
Pre Employ
Random
Post Accident
Reasonable Suspicion
Periodic
_________________
____________
__ _____
Date of Collection:
Time of Collection:
AM / PM
Specimen Type:
Oral Fluids
Urine
Temperature 90 - 100 ° F
YES
No
Lot #:
Remarks:
Certification Information: (Must be signed by both Donor and Collector)
I hereby certify that the specimen provided is my own and has not been substituted or adulterated, I further agree and
grant permission for the testing of my specimen for drug metabolites and/or alcohol. Also, I hereby give permission for the
release of the results of this test to my employer/prospective employer and/or their authorized Healthcare professionals.
Donor's Signature
Date
I hereby certify that I collected the specimen provided by the aforementioned Donor and that it was not substituted
or adulterated to the best of my knowledge. The specimen temperature and color were acceptable.
Collector's Signature
Date
Test Results: (Non-negative results must be confirmed by a Lab (using GC/MS)
Alcohol - ETG
Methadone - MTD
Adulteration
Negative for all
Amphetamines - AMP
Nicotine / Cotinine - COT
OX
Oxidant
Barbiturates - BAR
Opiates/Morphine - OPI
Specific
Positive -
for the
Buprenorphine - BUP
Oxycodone - OXY
SG
Gravity
drugs marked:
Benzodiazepine - BZO
Marijuana - THC
Cocaine - COC
Phencyclidine - PCP
pH
pH
Methamphetamine - mAMP
Propoxyphene - PPX
MDMA - MDMA
Tricyclic - TCA
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