DATJ 155 Multiple Drug/ Alcohol screening consent form

Title Page

Confirmation for 13 Drug Multi-Test cup and Alcomate Breath Alcohol test
Employee Name
Status
Please advise
Sample collection Date:
Date of Test (if different):
Any recent medication taken (covering the last 2 weeks)?
Please advise medication taken
Patients Statement:
I hereby consent to both a urine and breath test, used to detect or monitor the presence of alcohol and drugs (and their metabolites, along with checks for sample integrity) and accept that these tests do not constitute a violation of my human rights. In the event of a positive result, I understand the policy of DB Schenker . I accept the interpretation of my test results by the Assessor and Co-assessor, provided their interpretations match. I understand records of the results of these tests will be stored, processed and shared with my employer and I agree to this. By signing below, I confirm I am in receipt of the GDPR Information sheet explaining the data collected, how it is used, my rights in relation to it and the Data Protection Officer contact information.
Signed (Employee)
Signed (Assessor)
Position
Coassessor’s Name:
Position:
Date

Test

Test start time:
Test Result read at:
Lot Number:
Does the sample temperature strip indicate a body temperature between 32 - 38°C
The sample is valid
This is outside the normal temperatures of bodily fluids. To remove doubt of a substituted or tampered sample, the employee is required to provide another sample.

Following the test the presence of a "Control Line" was observed
The test is valid!
The test is invalid and must be restarted using new test pots/equipment.
Following the test, was there an indicator line on any of the substance test areas (Regardless of intensity).
The absence of a line on any of the substance test areas indicates the result of the test is "POSITIVE". Indicate which test areas a line was missing.
- 1. Methamphetamines
- 2. Cocaine
- 3. Cannabis (THC)
- 4. Amphetamines
- 5. Opiates (MOP
- 6. Benzodiazepines
- 7. Ecstasy (MDMA)
- 8. Methadone
- 9. Tramadol
- 10. Ketamine
The presence of a line on any of the substance test areas indicates the test is "NEGATIVE"

Following the test the presence of a control line was observed
The test is valid
The test is invalid and must be restarted using new test pots/equipment.
Following the test, was there an indicator line on any of the substance test areas (Regardless of intensity).
The presence of a line on any of the substance test areas indicates the test is "NEGATIVE".
The absence of a line on any of the substance test areas indicates the result of the test is "POSITIVE". Indicate which test areas a line was missing.
- 1. Methamphetamines
- 2. Cocaine
- 3. Cannabis (THC)
- 4. Amphetamines
- 5. Opiates (MOP
- 6. Benzodiazepines
- 7. Ecstasy (MDMA)
- 8. Methadone
- 9. Tramadol
- 10. Ketamine

The Employee
- Was found to be negative for all drugs listed and within normal range for adulteration / dilution
- Was found to be positive for the following drugs/sample integrity checks:
Of which, the following drugs were detected in the controlled test.
- 1. Methamphetamines
- 2. Cocaine
- 3. Cannabis (THC)
- 4. Amphetamines
- 5. Opiates (MOP
- 6. Benzodiazepines
- 7. Ecstasy (MDMA)
- 8. Methadone
- 9. Tramadol
- 10. Ketamine
Signed (Assessor)

Test Start time:
Results Read at:
Was the reading on the breath tester greater than 0.000% BAC?
What was the reading
The employee must remain in the private room and the breath test must be repeated 20 minutes after the 1st test.
2nd Test. - Was the reading on the breath tester greater than 0.000% BAC
What was the reading! (Photo evidence required)
The employee has failed the breath test for the presence of alcohol
The test indicates there is "NO" presence of alcohol in the sample.
The test indicates there is "NO" presence of alcohol in the sample.
Signed: (Assessor)
Signed: (Co-assessor)