Information
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Site conducted
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Conducted on
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Prepared by
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Location
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Company Entity
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Line Manager/Supervisor
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Worker/Staff Name
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Contact Number
Preliminary Questions
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Have you been informed of the Burbank Alcohol & Drug Policy (please select answer from drop down list)
- Burbank Induction
- Drug & Alcohol Info session
- Safety Alerts
- HSE weekly reviews
- Toolbox Talks
- Site notice Board
- other
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Please note response
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Have you attended the Alcohol and Drug information Session
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Have you taken any prescription/other medication today
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If so please list the medication
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I consent to the testing of my breath for a BAC level and oral fluids for drugs. I certify that the specimens tested are my own. Further, I certify that for any onsite testing perfromed. such testing was carried out in my presence. Also I certify that the information provided in this form is correct and I consent to the release of all test results to Burbank, my direct employer and regulatory authorities if so requested.
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Name and signature of person being tested
Alcohol Breath & Drug Saliva Test
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Select the elements being tested
- THC
- COC
- Meth
- MDMA
- AMP
- OPI
- BZO
- Alcohol
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Result
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Result
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Result
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Result
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Result
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Result
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Result
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Select type of test: Passive or Specific Reading
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Result
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Please insert straw and retest and write down reading
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Please list Non Negative Marker/s for saliva drug test
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Please take photos of all results
