AOD TEST RECORD FORM

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

Subject Details

• Subject name

• Photo ID

  Yes

  No

• Non-Photo ID

  Yes

  No

• Position held

• DOB

  Date

• Breath sample required

  Yes

  No

• Saliva sample required

  Yes

  No

Subject Certification/Consent/Declaration

• I consent to the collection and testing of my specimen using on-site equipment/test devices or via a NATA-accredited laboratory if required for confirmatory testing purposes. I understand that the test is being performed as part of the Schlam Alcohol & Other Drugs Policy and Procedure. I authorise the release and recording of the test result to the nominated Company representative, I also certify that the information supplied on this form is True and Correct.

• Subject signature

  Sign

• Date & time

  Date

• Testing Technician is to Complete the Remainder of this Form

Sample Collection

• Has the test subject consumed Food, Drink, or Cigarettes within the last 20 minutes?

  Yes

  No

• (SAMPLE CAN NOW BE COLLECTED)

• Date & time

  Date

• Testing Reason

  Select

• Location

• Subject ID type

• Subject ID No.

• Technicians Name

• Technicians Signature

  Sign

Results

• Time of Result

  Date

• Testing Device ID No

• Consumable Order Code

• Consumable Barcode No

• Initial Test Result

  Negative

  Non Negative

• In the event of a Non-Negative Result, insert comments in the Note section above

• BAC - %

• Evidentiary Test Result

  Negative

  Positive

• BAC - %

• AMP

  Yes

  No

• BZO

  Yes

  No

• COC

  Yes

  No

• MET

  Yes

  No

• OPI

  Yes

  No

• THC

  Yes

  No