"Ez-Cup Drug Screen Result Form - U.S. Diagnostics"

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EZ-Cup
Drug Screen Result Form
Company Information:
(information about the company doing the testing)
Company___________________________________________ Phone _____________
Address ______________________________________________ Fax _____________
City _____________________________ State ____________ Postal Code _________
Collector Name _____________________________________
Specimen Temperature: (90 – 100 F) In Range? (Circle response) YES NO
Donor Information:
(information about the person being tested)
Donor Name____________________________________________________________
Identification Type_________________________________ Expiration ___________
ID Number or SSN __________________________________
Certification Information:
(must be signed by Donor and Collector)
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.
Collection/Test Date
_________________________________________
__________________
Collector Signature
Date
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 urine specimen for drug metabolites and,
or alcohol.
________________________________________
___________________
Donor Signature
Date
Negative Result
Negative Result
Non-Negative Result
Invalid Result
This screen shows a
This Screen shows a
This screen shows an OPI
This screen shows an
NEGATIVE result
NEGATIVE result, even a very
NON-NEGATIVE result
INVALID result
light line
indicates a
result.
NEGATIVE
Drug Name
Device Code
Negative
Confirm
Not Tested
Adulterant Pads (If Provided)
Cocaine
COC
Marijuana
THC
Normal
Abnormal
Opiates/Morphine
OPI
Oxidants (OX)
Amphetamines
AMP
Specific Gravity (SG)
Methamphetamines
mAMP
Nitrates (NIT)
Methylendioxymethamphetamine MDMA
Acidity (pH)
Phencyclidine
PCP
Benzodiazepine
BZO
Glutaraldehyde (GLUT)
Barbiturates
BAR
Creatinine (CRE)
Methadone
MTD
Oxycodone
OXY
Tri-Cyclic Antidepressants
TCA
9-2004
EZ-Cup
Drug Screen Result Form
Company Information:
(information about the company doing the testing)
Company___________________________________________ Phone _____________
Address ______________________________________________ Fax _____________
City _____________________________ State ____________ Postal Code _________
Collector Name _____________________________________
Specimen Temperature: (90 – 100 F) In Range? (Circle response) YES NO
Donor Information:
(information about the person being tested)
Donor Name____________________________________________________________
Identification Type_________________________________ Expiration ___________
ID Number or SSN __________________________________
Certification Information:
(must be signed by Donor and Collector)
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.
Collection/Test Date
_________________________________________
__________________
Collector Signature
Date
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 urine specimen for drug metabolites and,
or alcohol.
________________________________________
___________________
Donor Signature
Date
Negative Result
Negative Result
Non-Negative Result
Invalid Result
This screen shows a
This Screen shows a
This screen shows an OPI
This screen shows an
NEGATIVE result
NEGATIVE result, even a very
NON-NEGATIVE result
INVALID result
light line
indicates a
result.
NEGATIVE
Drug Name
Device Code
Negative
Confirm
Not Tested
Adulterant Pads (If Provided)
Cocaine
COC
Marijuana
THC
Normal
Abnormal
Opiates/Morphine
OPI
Oxidants (OX)
Amphetamines
AMP
Specific Gravity (SG)
Methamphetamines
mAMP
Nitrates (NIT)
Methylendioxymethamphetamine MDMA
Acidity (pH)
Phencyclidine
PCP
Benzodiazepine
BZO
Glutaraldehyde (GLUT)
Barbiturates
BAR
Creatinine (CRE)
Methadone
MTD
Oxycodone
OXY
Tri-Cyclic Antidepressants
TCA
9-2004