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Drug and Alcohol Testing Consent & Chain of Custody Form

DONOR INFORMATION

Surname:

Given Name:

Date of Birth

Male or Female?

Address:
Take photo of ID/ license
REQUESTING AUTHORITY

Nominated Representative:

Company:

Position:

Telephone:

Email:

ID number:

DONOR CERTIFICATION/CONSENT/DECLARATION

I consent to the testing of my breath/urine/oral fluids sample for alcohol/drugs. I certify that the breath/urine/oral fluid specimen accompanying this form is my own and was provided by me to the authorized collector. Further, I certify that for any on-site testing performed, such testing was carried out in my presence. I certify that for any of my specimens that are to be sent for laboratory testing, the containers were sealed with tamper evident seals in my presence and that the information on the labels Is correct. Also I certify that the Information provided on this form is correct and I consent to the release of all test results together with all relevant details on this form to the nominated representative(s) of the requesting authority indicated above.

Other comments

DONOR Signature
COLLECTOR CERTIFICATION

I certify that I witnessed the donor signature and that the specimen identified on this form was provided to me by the donor whose consent and certification appears above, bears the same identification as set forth above, and that the urine/oral fluid specimen has been collected, divided, labelled and sealed in accordance with the relevant Standard.

COLLECTOR Name & Signature
Date and time of Collection:

Collection Site:

Colour

Creatinine Level

TEST RESULTS

Initial Testing Device/Method:

Batch Number:

Expiry Date:

Breathalyser Serial No:

INITIAL TEST RESULT
Drug/Drug Class
Select which Drug/Drug Class is tested (select all that apply)

Alcohol

COC

AMP

MET

THC

OPI

BZO

2ND TEST RESULT (alcohol only)

Alcohol

Collector/ Technician’s Name & Signature
CHAIN-OF-CUSTODY
Click ADD to add new Custody Information.
Received By
Date/Time Received

Seal Intact

Labels Match

Drug and Alcohol Testing Consent Form Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 40

Use this form as consent for conducting Drug and Alcohol Testing

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Drug and Alcohol Testing Consent & Chain of Custody Form

DONOR INFORMATION

Surname:

Given Name:

Date of Birth

Male or Female?

Address:
Take photo of ID/ license
REQUESTING AUTHORITY

Nominated Representative:

Company:

Position:

Telephone:

Email:

ID number:

DONOR CERTIFICATION/CONSENT/DECLARATION

I consent to the testing of my breath/urine/oral fluids sample for alcohol/drugs. I certify that the breath/urine/oral fluid specimen accompanying this form is my own and was provided by me to the authorized collector. Further, I certify that for any on-site testing performed, such testing was carried out in my presence. I certify that for any of my specimens that are to be sent for laboratory testing, the containers were sealed with tamper evident seals in my presence and that the information on the labels Is correct. Also I certify that the Information provided on this form is correct and I consent to the release of all test results together with all relevant details on this form to the nominated representative(s) of the requesting authority indicated above.

Other comments

DONOR Signature
COLLECTOR CERTIFICATION

I certify that I witnessed the donor signature and that the specimen identified on this form was provided to me by the donor whose consent and certification appears above, bears the same identification as set forth above, and that the urine/oral fluid specimen has been collected, divided, labelled and sealed in accordance with the relevant Standard.

COLLECTOR Name & Signature
Date and time of Collection:

Collection Site:

Colour

Creatinine Level

TEST RESULTS

Initial Testing Device/Method:

Batch Number:

Expiry Date:

Breathalyser Serial No:

INITIAL TEST RESULT
Drug/Drug Class
Select which Drug/Drug Class is tested (select all that apply)

Alcohol

COC

AMP

MET

THC

OPI

BZO

2ND TEST RESULT (alcohol only)

Alcohol

Collector/ Technician’s Name & Signature
CHAIN-OF-CUSTODY
Click ADD to add new Custody Information.
Received By
Date/Time Received

Seal Intact

Labels Match