"Drug Screen Report Form - Rapiddetectinc" - Oklahoma

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Drug Screen Report Form
Specimen ID #__________________ Collection Test Date_____________________
Company Information: (Company giving the test)
Company___________________________________________________________________________________________________
Address____________________________________________________________________________________________________
City______________________ State________________ Zip Code_____________________________________________________
Objective
Collectors Name______________________________ Phone_________________________________________________________
Experience
Specimen Temperature (90-100 F) Within Limits? Y / N Other__________________ Fax__________________________________
Donor Information: (Person being tested)
Donor’s Name__________________________________________ SSN_________________________________________________
ID #: ______________________________ ID Type: _________________ Expiration #: ____________________________________
Notes______________________________________________________________________________________________________
Certification Information: (Signatures of both parties required)
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.
________________________________________________
___________________________________
Donor’s Signature
Date
I hereby certify that I have 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
Initial Screen Results: (To be completed by screening personnel)
Drug Name
Device Code
Negative
Confirm
Not Tested
Cocaine
COC
Marijuana
THC
Opiates/Morphine
OPI/MOR
Amphetamine
AMP
Methamphetamine
mAMP
Phencyclidine
PCP
Benzodiazepine
BZO
Barbiturates
BAR
Methadone
MTD
Tricyclic
TCA
Antidepressants
Oxycodone
OXY
Propoxyphene
PPX
Ecstasy
MDMA
Alcohol Screen
ALC
Level ->
Adulteration
Oxidant
Specific Gravity
PH
Results
In Range
In Range
In Range
Other____________
Other____________
Other_____________
Drug Screen Report Form
Specimen ID #__________________ Collection Test Date_____________________
Company Information: (Company giving the test)
Company___________________________________________________________________________________________________
Address____________________________________________________________________________________________________
City______________________ State________________ Zip Code_____________________________________________________
Objective
Collectors Name______________________________ Phone_________________________________________________________
Experience
Specimen Temperature (90-100 F) Within Limits? Y / N Other__________________ Fax__________________________________
Donor Information: (Person being tested)
Donor’s Name__________________________________________ SSN_________________________________________________
ID #: ______________________________ ID Type: _________________ Expiration #: ____________________________________
Notes______________________________________________________________________________________________________
Certification Information: (Signatures of both parties required)
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.
________________________________________________
___________________________________
Donor’s Signature
Date
I hereby certify that I have 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
Initial Screen Results: (To be completed by screening personnel)
Drug Name
Device Code
Negative
Confirm
Not Tested
Cocaine
COC
Marijuana
THC
Opiates/Morphine
OPI/MOR
Amphetamine
AMP
Methamphetamine
mAMP
Phencyclidine
PCP
Benzodiazepine
BZO
Barbiturates
BAR
Methadone
MTD
Tricyclic
TCA
Antidepressants
Oxycodone
OXY
Propoxyphene
PPX
Ecstasy
MDMA
Alcohol Screen
ALC
Level ->
Adulteration
Oxidant
Specific Gravity
PH
Results
In Range
In Range
In Range
Other____________
Other____________
Other_____________